Provider Demographics
NPI:1023380375
Name:ROLLINS, DERRICK STACEY (BA)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:STACEY
Last Name:ROLLINS
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 LOYOLA AVE
Mailing Address - Street 2:106
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70113-1912
Mailing Address - Country:US
Mailing Address - Phone:504-558-9595
Mailing Address - Fax:504-558-9599
Practice Address - Street 1:701 LOYOLA AVE
Practice Address - Street 2:106
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70113-1912
Practice Address - Country:US
Practice Address - Phone:504-558-9595
Practice Address - Fax:504-558-9599
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator