Basic Information
| Provider Information | |||||||||
| NPI: | 1811106644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERIX | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRADSHAW | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | R. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1450 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654013648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733647551 | ||||||||
| FaxNumber: | 8163183045 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654013648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733647551 | ||||||||
| FaxNumber: | 8163183045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 06/17/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 8291 | NE | N | Behavioral Health & Social Service Providers | Counselor | 103TC0700X | 2008034835 | MO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 101YM0800X | 2008019412 | MO | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 470798717-29 | 05 | NE | MEDICAID | 98534 | 01 | NE | AUXILARY BCBS | OTHER | 470798717-27 | 05 | NE | MEDICAID | 470798717-26 | 05 | NE | MEDICAID |