Healthcare Provider Details

I. General information

NPI: 1083373856
Provider Name (Legal Business Name): DERRICK J. KIRKLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 CHANNINGWAY BLVD STE 6016100
COLUMBUS OH
43232-2910
US

IV. Provider business mailing address

4258 CONOVER PL
COLUMBUS OH
43227-2443
US

V. Phone/Fax

Practice location:
  • Phone: 614-626-8538
  • Fax:
Mailing address:
  • Phone: 614-980-7902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number00251
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: