Provider Demographics
NPI:1194548594
Name:FARRELL, DEREK ROBERT
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:ROBERT
Last Name:FARRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ARDEE AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5259
Mailing Address - Country:US
Mailing Address - Phone:631-617-0306
Mailing Address - Fax:
Practice Address - Street 1:9 ARDEE AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-5259
Practice Address - Country:US
Practice Address - Phone:631-617-0306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1253411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical