Healthcare Provider Details

I. General information

NPI: 1790018489
Provider Name (Legal Business Name): DERRICK COMMUNITY DEVELOPMENT & HUMAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2009
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5010 31ST ST
DETROIT MI
48210-2537
US

IV. Provider business mailing address

PO BOX 252982
WEST BLOOMFIELD MI
48325-2982
US

V. Phone/Fax

Practice location:
  • Phone: 313-915-2644
  • Fax:
Mailing address:
  • Phone: 313-915-2644
  • Fax: 248-661-5024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. CASSANDRA L DERRICK
Title or Position: PRESIDENT, CEO
Credential: BSHCS
Phone: 313-915-2644