Healthcare Provider Details

I. General information

NPI: 1891399689
Provider Name (Legal Business Name): DEZIREE MONTERVINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3661 CENTRAL AVE
FORT MYERS FL
33901-8218
US

IV. Provider business mailing address

3661 CENTRAL AVE
FORT MYERS FL
33901-8218
US

V. Phone/Fax

Practice location:
  • Phone: 239-245-8761
  • Fax:
Mailing address:
  • Phone: 239-245-8761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-26-2831772
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: