Healthcare Provider Details

I. General information

NPI: 1255260030
Provider Name (Legal Business Name): DEREK RUSSELL DEAN-DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S DIVISION ST
SPOKANE WA
99202-1510
US

IV. Provider business mailing address

107 S DIVISION ST
SPOKANE WA
99202-1510
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-4651
  • Fax:
Mailing address:
  • Phone: 509-838-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCAAR.CG.70127188
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: