Healthcare Provider Details

I. General information

NPI: 1811679590
Provider Name (Legal Business Name): MENSLEY DESROSIERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 03/18/2024
Certification Date: 03/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5530
US

IV. Provider business mailing address

298 HERITAGE ST SW
PALM BAY FL
32908
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax:
Mailing address:
  • Phone: 754-779-4426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: