Healthcare Provider Details

I. General information

NPI: 1144959461
Provider Name (Legal Business Name): DERRICK RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E WEBER RD STE 101
COLUMBUS OH
43211-1097
US

IV. Provider business mailing address

611 E WEBER RD STE 101
COLUMBUS OH
43211-1097
US

V. Phone/Fax

Practice location:
  • Phone: 614-615-3313
  • Fax:
Mailing address:
  • Phone: 614-615-3313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number188804
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: