Provider Demographics
NPI:1336381599
Name:MOORE, DERRYCK VANCURK (LADC)
Entity type:Individual
Prefix:MR
First Name:DERRYCK
Middle Name:VANCURK
Last Name:MOORE
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 25TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-4008
Mailing Address - Country:US
Mailing Address - Phone:612-220-8645
Mailing Address - Fax:952-405-8090
Practice Address - Street 1:12400 25TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-4008
Practice Address - Country:US
Practice Address - Phone:612-220-8645
Practice Address - Fax:952-405-8090
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301674101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)