Provider Demographics
NPI:1780370825
Name:WILLIAMS, DERRICK JOSE
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:JOSE
Last Name:WILLIAMS
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 1:2013 7TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44704-1969
Mailing Address - Country:US
Mailing Address - Phone:330-232-0379
Mailing Address - Fax:
Practice Address - Street 1:2013 7TH ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44704-1969
Practice Address - Country:US
Practice Address - Phone:330-232-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRP085271332U00000X, 376J00000X, 385H00000X, 385HR2055X, 385HR2060X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No332U00000XSuppliersHome Delivered Meals
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child