Provider Demographics
NPI:1023376084
Name:POLITE, DERRICK R (LMSW CASAC-T)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:R
Last Name:POLITE
Suffix:
Gender:M
Credentials:LMSW CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89-31 161TH STREET
Mailing Address - Street 2:ST. VINCENT SERVICES
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432
Mailing Address - Country:US
Mailing Address - Phone:718-206-0218
Mailing Address - Fax:718-206-1091
Practice Address - Street 1:89-31 161TH STREET
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-206-0218
Practice Address - Fax:718-206-1091
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72 085056104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker