Provider Demographics
NPI:1780329367
Name:WATSON, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:WATSON
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 1:1139 PENNFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1577
Mailing Address - Country:US
Mailing Address - Phone:216-246-1379
Mailing Address - Fax:
Practice Address - Street 1:26055 EMERY RD STE G
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-6211
Practice Address - Country:US
Practice Address - Phone:216-342-4445
Practice Address - Fax:216-342-4443
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator