Provider Demographics
NPI:1508581158
Name:DERRICK, DARLENE (CPRC)
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:CPRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2943
Mailing Address - Country:US
Mailing Address - Phone:313-344-9099
Mailing Address - Fax:
Practice Address - Street 1:1660 OAKMAN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-2791
Practice Address - Country:US
Practice Address - Phone:313-305-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)