Healthcare Provider Details

I. General information

NPI: 1396396495
Provider Name (Legal Business Name): DESIRAY LAVON GREER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 S FERDON BLVD
CRESTVIEW FL
32536-5252
US

IV. Provider business mailing address

103 LEWIS ST
FORT WALTON BEACH FL
32547-3142
US

V. Phone/Fax

Practice location:
  • Phone: 850-362-6824
  • Fax: 850-362-6826
Mailing address:
  • Phone: 850-362-6824
  • Fax: 850-362-6826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12156058
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: