Provider Demographics
NPI:1881170249
Name:RACICKI, DEREK ROBERT (MSSA, MA, LISW-S)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:ROBERT
Last Name:RACICKI
Suffix:
Gender:M
Credentials:MSSA, MA, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6382 BIRCHDALE CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-3635
Mailing Address - Country:US
Mailing Address - Phone:216-702-6994
Mailing Address - Fax:
Practice Address - Street 1:3200 VINE ST.
Practice Address - Street 2:CINCINNATI VA MEDICAL CENTER
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220
Practice Address - Country:US
Practice Address - Phone:513-861-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1500815-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical