Healthcare Provider Details

I. General information

NPI: 1851834089
Provider Name (Legal Business Name): DERRICK D THOMAS CDCA, NREMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2016
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21120 FULLER AVE
EUCLID OH
44123-2710
US

IV. Provider business mailing address

2738 ABBOTS COVE BLVD
COLUMBUS OH
43204-4335
US

V. Phone/Fax

Practice location:
  • Phone: 216-432-8178
  • Fax:
Mailing address:
  • Phone: 216-432-8178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number1828893
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number156613
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.172768
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: