Provider Demographics
NPI:1396999546
Name:HUMPHREY, DERRICK (MS ED, LMHC)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:MS ED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2545
Mailing Address - Street 2:
Mailing Address - City:GOLDENROD
Mailing Address - State:FL
Mailing Address - Zip Code:32733-2545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 S EUSTIS ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4886
Practice Address - Country:US
Practice Address - Phone:321-696-5598
Practice Address - Fax:407-453-4077
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH-10589101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health