Provider Demographics
NPI:1639696479
Name:DOS SANTOS, DERRICK QUINN
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:QUINN
Last Name:DOS SANTOS
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 1:6400 SOUTHCENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2547
Mailing Address - Country:US
Mailing Address - Phone:206-901-2000
Mailing Address - Fax:951-530-5945
Practice Address - Street 1:600 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5229
Practice Address - Country:US
Practice Address - Phone:206-302-2600
Practice Address - Fax:951-530-5945
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60790952101Y00000X
101Y00000X, 171M00000X, 172V00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker