Basic Information
| Provider Information | |||||||||
| NPI: | 1679040901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMPSON | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | LOREN | ||||||||
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| Credential: | MS, SUDT, MHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 112TH ST E | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984465307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535366425 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12201 PACIFIC AVE S | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984445126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535366425 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO60749434 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | CG60832062 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.