MEDICARE: MR. DOUGLAS DEGUIRE JR. MBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1295353191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS DEGUIRE JR. MBA

Provider Business Mailing Address
First Line	:	816 E 218TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-5806
Country	:	US
Telephone Number	:	917-346-3382
Fax Number	:

Provider Business Practice Location Address
First Line	:	816 E 218TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-5806
Country	:	US
Telephone Number	:	917-346-3382
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2020
Last Update Date	:	07/08/2020

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