Provider Demographics
NPI:1003412909
Name:SHEMIAH R DERRICK INC.
Entity Type:Organization
Organization Name:SHEMIAH R DERRICK INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEMIAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CADC
Authorized Official - Phone:773-424-2007
Mailing Address - Street 1:6127 S UNIVERSITY AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-5894
Mailing Address - Country:US
Mailing Address - Phone:773-424-2007
Mailing Address - Fax:
Practice Address - Street 1:6127 S UNIVERSITY AVE STE 109
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-5894
Practice Address - Country:US
Practice Address - Phone:773-424-2007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)