Doctor Name: | JAMES K DERCKS |
NPI Number: | 1134586779 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | LPC-IT |
License Number: | |
Business Practice Address: | 1810 Appleton Rd Menasha, WI - 549521110 |
Business Phone Number: | 9207394226 |
Business Fax Number: | 9207397639 |
Mailing Address: | 1810 Appleton Rd, MENASHA |
State: | WI |
Postal Code: | 549521110 |
Phone Number: | 9207394226 |
Fax Number: | 9207397639 |
NPI Enumeration Date: | 01/27/2016 |
NPI Last Update Date: | 01/27/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |