Healthcare Provider Details

I. General information

NPI: 1023680865
Provider Name (Legal Business Name): DESHAUN BAYNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BROADHOLLOW RD STE 402
MELVILLE NY
11747-4899
US

IV. Provider business mailing address

212 S 6TH ST
LINDENHURST NY
11757-4631
US

V. Phone/Fax

Practice location:
  • Phone: 631-385-7780
  • Fax: 631-385-7795
Mailing address:
  • Phone: 516-499-2064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-73349
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: