Healthcare Provider Details

I. General information

NPI: 1023787512
Provider Name (Legal Business Name): DERRICK ANTHONY WRIGHT LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 21ST ST
OAKLAND CA
94612-1605
US

IV. Provider business mailing address

525 21ST ST
OAKLAND CA
94612-1605
US

V. Phone/Fax

Practice location:
  • Phone: 323-875-5449
  • Fax:
Mailing address:
  • Phone: 510-899-1645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150105283
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: