Susan M Derivas, CNP

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

64266 Issued in ID

Practice address

4055 E Blueberry St
Meridian, ID 83642-8261

Phone

(208) 775-7418

Fax

(208) 647-5008

NPI assigned

Sep 1, 2006

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 9

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

Credentials

Certified Nurse Practitioner, Nurse Practitioner

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Telemental Health Link LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Albuquerque, NM
  • NPI 1972367290

  Multi-Specialty

  NPD Authorized official
• Meridian Advanced Psychiatry , LLC

  • Addiction Medicine (Psychiatry & Neurology) Physician
  • Meridan, ID
  • NPI 1609412683

  Multi-Specialty

  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1157068800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1707264000000",
    "number": "1851493829",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4055 E BLUEBERRY ST",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836428261",
            "telephone_number": "208-775-7418",
            "fax_number": "208-674-5008"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4055 E BLUEBERRY ST",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836428261",
            "telephone_number": "208-775-7418",
            "fax_number": "208-647-5008"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5700 Harper Dr NE Ste 210-4",
            "address_purpose": "LOCATION",
            "city": "Albuquerque",
            "state": "NM",
            "postal_code": "871093573",
            "country_code": "US",
            "telephone_number": "208-775-7418",
            "fax_number": "208-647-5008",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DERIVAS",
        "first_name": "SUSAN",
        "middle_name": "M",
        "name_prefix": "Ms.",
        "credential": "CNP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-09-01",
        "last_updated": "2024-02-07",
        "certification_date": "2024-02-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "ID",
            "license": "64266",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SPRUCE HEALTH",
            "identifier": "208-775-7418",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1032026",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EVERNORTH",
            "identifier": "5708247",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AVAILITY ID",
            "identifier": "932434",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED HEALTHCARE SERVICES, PROVIDER NO.",
            "identifier": "0062-0104069",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAQH PROVIDER ID",
            "identifier": "13961493",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CHANGE HEALTHCARE SUBMITTER ID",
            "identifier": "909072",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLOZAPINE REMS CERTIFIED",
            "identifier": "1851493829",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MASTER BILLING ID (OSMIND)",
            "identifier": "396453",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Gayle Jean Detweiler, P.A.
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• All providers in Meridian, ID
• Psychiatric/Mental Health Nurse Practitioner in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 7, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.