Healthcare Provider Details

I. General information

NPI: 1184530628
Provider Name (Legal Business Name): MAX DORMEVILLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVE SE
GRAND RAPIDS MI
49546-3691
US

IV. Provider business mailing address

1845 CLAY ST
KISSIMMEE FL
34741-6317
US

V. Phone/Fax

Practice location:
  • Phone: 973-419-2877
  • Fax:
Mailing address:
  • Phone: 973-419-2877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: