Provider Demographics
NPI:1144908492
Name:LATTIMER, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LATTIMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 491000
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-1000
Mailing Address - Country:US
Mailing Address - Phone:352-315-7500
Mailing Address - Fax:
Practice Address - Street 1:2140 N DON WICKHAM DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1922
Practice Address - Country:US
Practice Address - Phone:352-394-5922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH22442OtherSTATE OF FLORIDA