Healthcare Provider Details

I. General information

NPI: 1174993257
Provider Name (Legal Business Name): MR. DERRICK ALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8706 JEFFERSON HWY STE A
BATON ROUGE LA
70809-2233
US

IV. Provider business mailing address

PO BOX 423
BAKER LA
70704-0423
US

V. Phone/Fax

Practice location:
  • Phone: 225-926-9706
  • Fax: 225-926-9708
Mailing address:
  • Phone: 225-772-3334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5113
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: