=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528877511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERRICK HUMPHREY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2025
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3625 14TH ST
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-955-1540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3234 S CANTONA PASEO
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91762-7427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-302-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | ASW122399
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------