Provider Demographics
NPI:1962095398
Name:BAYNE, DEREK (MA, NCC, LPC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BAYNE
Suffix:
Gender:M
Credentials:MA, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 HAWK MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-5729
Mailing Address - Country:US
Mailing Address - Phone:719-464-3179
Mailing Address - Fax:
Practice Address - Street 1:1283 KELLY JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3925
Practice Address - Country:US
Practice Address - Phone:719-452-4803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0018053101YM0800X
COLPC.0018940101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health