Healthcare Provider Details

I. General information

NPI: 1023877990
Provider Name (Legal Business Name): DERRICK LEE HAGLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E SELTICE WAY STE 101
POST FALLS ID
83854-5336
US

IV. Provider business mailing address

601 E SELTICE WAY STE 101
POST FALLS ID
83854-5336
US

V. Phone/Fax

Practice location:
  • Phone: 208-676-1075
  • Fax:
Mailing address:
  • Phone: 208-676-1075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1771352
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: