Healthcare Provider Details

I. General information

NPI: 1689719965
Provider Name (Legal Business Name): DERON MASON HASKINS M.A., R.A.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E WARDLOW RD
LONG BEACH CA
90807-4417
US

IV. Provider business mailing address

731 W 148TH ST
GARDENA CA
90247-2717
US

V. Phone/Fax

Practice location:
  • Phone: 562-427-6818
  • Fax:
Mailing address:
  • Phone: 310-217-9338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCERT# H0412241242
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLBSW# 21021
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: