MEDICARE: DERRICK COMMUNITY DEVELOPMENT & HUMAN SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1790018489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERRICK COMMUNITY DEVELOPMENT & HUMAN SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 252982
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48325-2982
Country	:	US
Telephone Number	:	313-915-2644
Fax Number	:	248-661-5024

Provider Business Practice Location Address
First Line	:	5010 31ST ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48210-2537
Country	:	US
Telephone Number	:	313-915-2644
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, CEO
Name	:	MRS. CASSANDRA L DERRICK
Credential	:	BSHCS
Telephone Number	:	313-915-2644

Provider Enumeration Date	:	09/12/2009
Last Update Date	:	01/28/2010

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