Provider Demographics
NPI:1316456197
Name:DERKSON, BILL (LCDCII)
Entity type:Individual
Prefix:
First Name:BILL
Middle Name:
Last Name:DERKSON
Suffix:
Gender:M
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 W BROAD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-2653
Mailing Address - Country:US
Mailing Address - Phone:614-272-7005
Mailing Address - Fax:614-272-7008
Practice Address - Street 1:3035 W BROAD ST STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-2653
Practice Address - Country:US
Practice Address - Phone:614-272-7005
Practice Address - Fax:614-272-7008
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121071101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)