Healthcare Provider Details

I. General information

NPI: 1437821790
Provider Name (Legal Business Name): DERRICK WHITE CASAC-T,CRPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 RICHMOND AVE
STATEN ISLAND NY
10312-5110
US

IV. Provider business mailing address

321 ODER AVE
STATEN ISLAND NY
10304-3327
US

V. Phone/Fax

Practice location:
  • Phone: 718-948-3232
  • Fax:
Mailing address:
  • Phone: 917-674-9368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37149
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: