Healthcare Provider Details

I. General information

NPI: 1487040143
Provider Name (Legal Business Name): DANIEL PREVOST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 DOUGLAS AVE.
ALTAMONTE SPRINGS FL
32714
US

IV. Provider business mailing address

139 MAYFAIR CIR
SANFORD FL
32771-0000
US

V. Phone/Fax

Practice location:
  • Phone: 305-814-3087
  • Fax:
Mailing address:
  • Phone: 305-814-3087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: