Healthcare Provider Details

I. General information

NPI: 1891642179
Provider Name (Legal Business Name): STILLWATER HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3256 W POTOMAC AVE
CHICAGO IL
60651-2411
US

IV. Provider business mailing address

3256 W POTOMAC AVE
CHICAGO IL
60651-2411
US

V. Phone/Fax

Practice location:
  • Phone: 708-280-6164
  • Fax:
Mailing address:
  • Phone: 708-280-6164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: CAROLLE DERRADJI
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 708-280-6164