Provider Demographics
NPI:1942855077
Name:DERICHS, CHARMAGNE (MA, LPCC)
Entity type:Individual
Prefix:
First Name:CHARMAGNE
Middle Name:
Last Name:DERICHS
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7137 CHICAGO AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3363
Mailing Address - Country:US
Mailing Address - Phone:320-282-4625
Mailing Address - Fax:
Practice Address - Street 1:6363 FRANCE AVE S STE 200
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2140
Practice Address - Country:US
Practice Address - Phone:952-903-1392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01574101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health