Individual
MR. DERRYCK VANCURK MOORE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LADC
Contact information
Practice address
12400 25TH AVE N, PLYMOUTH, MN 55441-4008
(612) 220-8645
(952) 405-8090
Mailing address
12400 25TH AVE N, PLYMOUTH, MN 55441-4008
(612) 220-8645
(952) 405-8090
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
301674
MN
Other
Enumeration date
04/01/2009
Last updated
04/01/2009
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