Provider Demographics
NPI:1114627296
Name:RICHARD, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:RICHARD
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 1:576 LOGAN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-3702
Mailing Address - Country:US
Mailing Address - Phone:929-526-8414
Mailing Address - Fax:646-905-8487
Practice Address - Street 1:576 LOGAN ST STE 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-3702
Practice Address - Country:US
Practice Address - Phone:929-526-8414
Practice Address - Fax:646-905-8487
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No251B00000XAgenciesCase Management