Provider Demographics
NPI:1790061430
Name:DETRICK, DOUGLAS JOHN (CADC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JOHN
Last Name:DETRICK
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 11TH ST
Mailing Address - Street 2:#113
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-2118
Mailing Address - Country:US
Mailing Address - Phone:515-988-1800
Mailing Address - Fax:
Practice Address - Street 1:1801 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1505
Practice Address - Country:US
Practice Address - Phone:515-282-6624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA11011104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA426005830OtherTAX ID NUMBER