Healthcare Provider Details

I. General information

NPI: 1376424259
Provider Name (Legal Business Name): DERRICK GIVENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W BRADLEY PL STE 100
CHICAGO IL
60618-4716
US

IV. Provider business mailing address

4042 S WABASH AVE
CHICAGO IL
60653-2153
US

V. Phone/Fax

Practice location:
  • Phone: 877-552-6672
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149028878
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: