Basic Information
| Provider Information | |||||||||
| NPI: | 1710202130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHI | ||||||||
| FirstName: | DERICK | ||||||||
| MiddleName: | KUMBA | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8901 N OLIE AVE | ||||||||
| Address2: | APT 4 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731142540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405658223 | ||||||||
| FaxNumber: | 4055281802 | ||||||||
| Practice Location | |||||||||
| Address1: | 27777 INKSTER RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483345326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484364400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2010 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | OK | N | Behavioral Health & Social Service Providers | Counselor | 106S00000X | Y |
No ID Information.