Provider Demographics
NPI:1174125223
Name:WHISMAN, DERICK RICHARD
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:RICHARD
Last Name:WHISMAN
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 1:6682 E TYGARTS RD
Mailing Address - Street 2:
Mailing Address - City:GREENUP
Mailing Address - State:KY
Mailing Address - Zip Code:41144-6544
Mailing Address - Country:US
Mailing Address - Phone:606-585-2471
Mailing Address - Fax:
Practice Address - Street 1:6682 E TYGARTS RD
Practice Address - Street 2:
Practice Address - City:GREENUP
Practice Address - State:KY
Practice Address - Zip Code:41144-6544
Practice Address - Country:US
Practice Address - Phone:606-585-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services