Active NPI
David James Derita, PHD
- Clinical Psychologist
- Tower Lakes, IL
National Provider Identifier
1124253547
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 071-002434
- Practice address
- 215 W Lake Shore Dr
Tower Lakes, IL 60010-1130 - Phone
- (847) 526-6557
- NPI assigned
- May 29, 2009
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 071-002434 | IL | Primary |
Addresses
Primary practice location
215 W Lake Shore Dr
Tower Lakes, IL 60010-1130
Mailing address
215 W Lake Shore Dr
Tower Lakes, IL 60010-1130
Phone (847) 526-6557
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 071-002434 | IL | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1243555200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1243555200000",
"number": "1124253547",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "215 W LAKE SHORE DR",
"city": "TOWER LAKES",
"state": "IL",
"postal_code": "600101130",
"telephone_number": "847-526-6557"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "215 W LAKE SHORE DR",
"city": "TOWER LAKES",
"state": "IL",
"postal_code": "600101130",
"telephone_number": "847-526-6557"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DERITA",
"first_name": "DAVID",
"middle_name": "JAMES",
"name_prefix": "Mr.",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2009-05-29",
"last_updated": "2009-05-29",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "IL",
"license": "071-002434",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Tower Lakes, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.