Healthcare Provider Details

I. General information

NPI: 1629780341
Provider Name (Legal Business Name): LOUIS VANDERLICK IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 W NASA BLVD # C-1
MELBOURNE FL
32901-2614
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY STE 200
LAKE MARY FL
32746-5028
US

V. Phone/Fax

Practice location:
  • Phone: 321-235-6199
  • Fax: 321-821-1975
Mailing address:
  • Phone: 610-866-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: