Basic Information
Provider Information | |||||||||
NPI: | 1447779947 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRATT | ||||||||
FirstName: | DEREK | ||||||||
MiddleName: | ANTHONY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4713 ANGELES VISTA BLVD | ||||||||
Address2: |   | ||||||||
City: | VIEW PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 900431147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3108006230 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 N SAN ANTONIO RD BLDG 3 | ||||||||
Address2: |   | ||||||||
City: | SANTA BARBARA | ||||||||
State: | CA | ||||||||
PostalCode: | 931101316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056815450 | ||||||||
FaxNumber: | 8056814747 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2017 | ||||||||
LastUpdateDate: | 06/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | A4666844 | 05 | CA |   | MEDICAID |