Healthcare Provider Details

I. General information

NPI: 1467856427
Provider Name (Legal Business Name): DERRICK COLLINS M.S.W
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 08/12/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 STARLING DR
DAYTONA BEACH FL
32117-1886
US

IV. Provider business mailing address

19 STARLING DR
DAYTONA BEACH FL
32117-1886
US

V. Phone/Fax

Practice location:
  • Phone: 386-262-9852
  • Fax:
Mailing address:
  • Phone: 386-262-9852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: