Healthcare Provider Details

I. General information

NPI: 1114696978
Provider Name (Legal Business Name): MR. DEREK JOHN MACFARLANE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date: 09/10/2026
Reactivation Date: 09/15/2026

III. Provider practice location address

3900 W BROAD ST
RICHMOND VA
23230-3914
US

IV. Provider business mailing address

3900 W BROAD ST
RICHMOND VA
23230-3914
US

V. Phone/Fax

Practice location:
  • Phone: 804-353-4461
  • Fax:
Mailing address:
  • Phone: 804-353-4461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904019435
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: