Healthcare Provider Details

I. General information

NPI: 1619402187
Provider Name (Legal Business Name): MR. DERRICK MICHAEL KUGEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15004 TURTLE LAKE CT
LUTZ FL
33559-7728
US

IV. Provider business mailing address

15004 TURTLE LAKE CT
LUTZ FL
33559-7728
US

V. Phone/Fax

Practice location:
  • Phone: 813-728-4276
  • Fax:
Mailing address:
  • Phone: 813-728-4276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberK240173944220
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: