Healthcare Provider Details

I. General information

NPI: 1124561865
Provider Name (Legal Business Name): DERRICK M. ARCIAGA LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4556 15TH AVE S
SEATTLE WA
98108-1818
US

IV. Provider business mailing address

4556 15TH AVE S
SEATTLE WA
98108-1818
US

V. Phone/Fax

Practice location:
  • Phone: 206-265-2935
  • Fax:
Mailing address:
  • Phone: 206-265-2935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60966243
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberLW60966243
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: