Provider Demographics
NPI:1912264581
Name:DERBY, SUZANNE
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:DERBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4634 HARMONY LN
Mailing Address - Street 2:
Mailing Address - City:EFLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27243-9456
Mailing Address - Country:US
Mailing Address - Phone:919-428-3833
Mailing Address - Fax:
Practice Address - Street 1:4634 HARMONY LN
Practice Address - Street 2:
Practice Address - City:EFLAND
Practice Address - State:NC
Practice Address - Zip Code:27243-9456
Practice Address - Country:US
Practice Address - Phone:919-428-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NCP0162361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst