Healthcare Provider Details

I. General information

NPI: 1295575710
Provider Name (Legal Business Name): ANDREW DONALD DECORT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 HERNDON ST
DOVER FL
33527-6350
US

IV. Provider business mailing address

2204 HERNDON ST
DOVER FL
33527-6350
US

V. Phone/Fax

Practice location:
  • Phone: 813-767-6991
  • Fax:
Mailing address:
  • Phone: 813-767-6991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-350818
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: