Provider Demographics
NPI:1629574090
Name:HOARD, DERRICK JAVAN
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:JAVAN
Last Name:HOARD
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 1:116 DUGOUT LN
Mailing Address - Street 2:
Mailing Address - City:STERLINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:71280-3317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 DUGOUT LN
Practice Address - Street 2:
Practice Address - City:STERLINGTON
Practice Address - State:LA
Practice Address - Zip Code:71280-3317
Practice Address - Country:US
Practice Address - Phone:318-732-7489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6489101YM0800X
LA1291101YM0800X
WA60822202101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty