Basic Information
| Provider Information | |||||||||
| NPI: | 1922298991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERRY | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCKISSON | ||||||||
| OtherFirstName: | JULIA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1485 S M-139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699250585 | ||||||||
| FaxNumber: | 2699271326 | ||||||||
| Practice Location | |||||||||
| Address1: | 1485 S M-139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699250585 | ||||||||
| FaxNumber: | 2699271326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 6301008191 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
No ID Information.