Provider Demographics
NPI:1548759699
Name:THOMAS, DEREK TIMOTHY (LICDC-CS, LPCC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:TIMOTHY
Last Name:THOMAS
Suffix:
Gender:M
Credentials:LICDC-CS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 E BUCHTEL AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44305-2338
Mailing Address - Country:US
Mailing Address - Phone:330-535-8116
Mailing Address - Fax:
Practice Address - Street 1:885 E BUCHTEL AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305-2338
Practice Address - Country:US
Practice Address - Phone:330-535-8116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162017101YA0400X
OHE.2404724101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH166425Medicaid