Provider Demographics
NPI:1083373856
Name:KIRKLAND, DERRICK J
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:J
Last Name:KIRKLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4258 CONOVER PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-2443
Mailing Address - Country:US
Mailing Address - Phone:614-980-7902
Mailing Address - Fax:
Practice Address - Street 1:6100 CHANNINGWAY BLVD STE 6016100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-2910
Practice Address - Country:US
Practice Address - Phone:614-626-8538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OH00251101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1437699543Medicaid