Provider Demographics
NPI:1194123778
Name:DERRICK, TINA (LMSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 14TH PL STE A
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1245
Mailing Address - Country:US
Mailing Address - Phone:515-235-5224
Mailing Address - Fax:
Practice Address - Street 1:1063 14TH PL STE A
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1245
Practice Address - Country:US
Practice Address - Phone:515-235-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA075285104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA600884423Medicaid