Provider Demographics
NPI:1881336907
Name:DERRICKSON, EBONY NICOLE (MS DDP)
Entity type:Individual
Prefix:MS
First Name:EBONY
Middle Name:NICOLE
Last Name:DERRICKSON
Suffix:
Gender:F
Credentials:MS DDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 GAINES SCHOOL RD APT I156
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-3254
Mailing Address - Country:US
Mailing Address - Phone:706-296-4666
Mailing Address - Fax:
Practice Address - Street 1:125 LEE BYRD RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2310
Practice Address - Country:US
Practice Address - Phone:678-883-8609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-09
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103TC1900X
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling