Provider Demographics
NPI:1194332676
Name:DERRICK, COURTNEY (LPCC, LICDC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:LPCC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3028
Mailing Address - Country:US
Mailing Address - Phone:614-334-6903
Mailing Address - Fax:
Practice Address - Street 1:3409 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1064
Practice Address - Country:US
Practice Address - Phone:380-201-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161741101YA0400X
OHE.2203162101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)