Provider Demographics
NPI:1972158814
Name:DERRY, SANDY A (ACLC)
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:A
Last Name:DERRY
Suffix:
Gender:F
Credentials:ACLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-3649
Mailing Address - Country:US
Mailing Address - Phone:406-395-6950
Mailing Address - Fax:
Practice Address - Street 1:521 4TH ST
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-3649
Practice Address - Country:US
Practice Address - Phone:406-395-6950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)