Basic Information
| Provider Information | |||||||||
| NPI: | 1689719965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HASKINS | ||||||||
| FirstName: | DERON | ||||||||
| MiddleName: | MASON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.A., R.A.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 W 148TH ST | ||||||||
| Address2: | |||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902472717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102179338 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 E WARDLOW RD | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908074417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624276818 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CERT# H0412241242 | CA | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | LBSW# 21021 | TX | X | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 23706 | 01 | CA | DV COUNSELOR | OTHER | H0412241242 | 01 | CA | REGISTERED ADDICTION SPEC | OTHER |