Basic Information
| Provider Information | |||||||||
| NPI: | 1760859813 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DERRICK FREEMAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5630 CROWDER BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701272429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049059670 | ||||||||
| FaxNumber: | 5042416007 | ||||||||
| Practice Location | |||||||||
| Address1: | 5630 CROWDER BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701272429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049059670 | ||||||||
| FaxNumber: | 5042416007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2015 | ||||||||
| LastUpdateDate: | 08/25/2015 | ||||||||
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| AuthorizedOfficialLastName: | FREEMAN | ||||||||
| AuthorizedOfficialFirstName: | DERRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5049059670 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | SA0010691 | LA | Y | Agencies | Community/Behavioral Health |
No ID Information.