Provider Demographics
NPI:1366907818
Name:DERRY VICK, HEATHER (PHD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:DERRY VICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:DERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:48 47TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-7154
Mailing Address - Country:US
Mailing Address - Phone:412-554-0120
Mailing Address - Fax:
Practice Address - Street 1:3512 QUENTIN RD STE 110
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4245
Practice Address - Country:US
Practice Address - Phone:718-854-8370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023019-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical