Provider Demographics
NPI:1942456959
Name:BRADDICK, DERRICK ADRIAN
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:ADRIAN
Last Name:BRADDICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRAD
Other - Middle Name:
Other - Last Name:BRADDICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8086 S YALE AVE
Mailing Address - Street 2:#236
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-9003
Mailing Address - Country:US
Mailing Address - Phone:918-407-6426
Mailing Address - Fax:
Practice Address - Street 1:2725 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6241
Practice Address - Country:US
Practice Address - Phone:918-407-8847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-10
Last Update Date:2008-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor