Provider Demographics
NPI:1922598143
Name:HAITHCOCK, DERRIK RICHARD SR (LCDC LLL)
Entity Type:Individual
Prefix:MR
First Name:DERRIK
Middle Name:RICHARD
Last Name:HAITHCOCK
Suffix:SR
Gender:M
Credentials:LCDC LLL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E MCMILLAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1922
Mailing Address - Country:US
Mailing Address - Phone:513-221-3350
Mailing Address - Fax:
Practice Address - Street 1:1071 TONG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:45612-1500
Practice Address - Country:US
Practice Address - Phone:740-634-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHLCDCIII.161470101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator