Provider Demographics
NPI:1568923902
Name:CASEY, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:CASEY
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 1:442 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2328
Mailing Address - Country:US
Mailing Address - Phone:774-253-3914
Mailing Address - Fax:
Practice Address - Street 1:484 MAIN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1893
Practice Address - Country:US
Practice Address - Phone:508-799-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS96930234OtherDRIVER'S LICENSE