Ebony Nicole Derrickson, MS DDP

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

Practice address

125 Lee Byrd Rd
Loganville, GA 30052-2310

Phone

(678) 883-8609

NPI assigned

Apr 9, 2022

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

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

{
    "created_epoch": "1649462400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1649462400000",
    "number": "1881336907",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "750 GAINES SCHOOL RD APT I156",
            "city": "ATHENS",
            "state": "GA",
            "postal_code": "306053254",
            "telephone_number": "706-296-4666"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "125 LEE BYRD RD",
            "city": "LOGANVILLE",
            "state": "GA",
            "postal_code": "300522310",
            "telephone_number": "678-883-8609"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2795 Main St W",
            "address_purpose": "LOCATION",
            "city": "Snellville",
            "state": "GA",
            "postal_code": "300783164",
            "country_code": "US",
            "telephone_number": "678-334-7836",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DERRICKSON",
        "first_name": "EBONY",
        "middle_name": "NICOLE",
        "name_prefix": "Ms.",
        "credential": "MS DDP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-04-09",
        "last_updated": "2022-04-09",
        "certification_date": "2022-04-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "",
            "desc": "Counselor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "",
            "desc": "Psychologist, Counseling",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Mental Health Counselor in Loganville, GA
• Providers in Loganville, GA by specialty
• Mental Health Counselor in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.