Healthcare Provider Details

I. General information

NPI: 1720930332
Provider Name (Legal Business Name): DERRICK BAINES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2026
Last Update Date: 02/14/2026
Certification Date: 02/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 N 31ST AVE
OMAHA NE
68111-1211
US

IV. Provider business mailing address

6201 N 31ST AVE
OMAHA NE
68111-1211
US

V. Phone/Fax

Practice location:
  • Phone: 402-376-9998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: