Individual
DERRICK BACON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
906 69TH AVE, PHILADELPHIA, PA 19126-2909
(215) 300-8111
Mailing address
906 69TH AVE, PHILADELPHIA, PA 19126-2909
(215) 300-8111
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
Other
Enumeration date
04/25/2018
Last updated
04/25/2018
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