Provider Demographics
NPI:1366151995
Name:NOVACEK, DEREK MATTHEW (PHD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:MATTHEW
Last Name:NOVACEK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18615 E ARROW HWY APT 228
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-1836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:351 E TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3328
Practice Address - Country:US
Practice Address - Phone:213-253-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA114340103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical