Provider Demographics
NPI:1073810057
Name:HALE, DERRICK F
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:F
Last Name:HALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16146 PETOSKEY AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-3045
Mailing Address - Country:US
Mailing Address - Phone:313-570-4437
Mailing Address - Fax:
Practice Address - Street 1:1852 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1006
Practice Address - Country:US
Practice Address - Phone:313-894-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker