Healthcare Provider Details

I. General information

NPI: 1508471830
Provider Name (Legal Business Name): DERRICK L VICTORIAN M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2749 GRAND AVE
WAUKEGAN IL
60085-2406
US

IV. Provider business mailing address

415 S LINCOLN AVE
WAUKEGAN IL
60085-6345
US

V. Phone/Fax

Practice location:
  • Phone: 773-644-7787
  • Fax:
Mailing address:
  • Phone: 847-445-5192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: