Provider Demographics
NPI:1285471656
Name:DERRY, JUSTIN (LMHC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:DERRY
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4361 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51022-7531
Mailing Address - Country:US
Mailing Address - Phone:712-334-0083
Mailing Address - Fax:
Practice Address - Street 1:4361 MONROE AVE
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:IA
Practice Address - Zip Code:51022-7531
Practice Address - Country:US
Practice Address - Phone:712-334-0083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA113268101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health