Healthcare Provider Details

I. General information

NPI: 1225668817
Provider Name (Legal Business Name): DERIK ESCOBEDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 VILLAGE DR
BROWNSVILLE TX
78521-1480
US

IV. Provider business mailing address

2424 VILLAGE DR
BROWNSVILLE TX
78521-1480
US

V. Phone/Fax

Practice location:
  • Phone: 956-431-0056
  • Fax: 832-553-7287
Mailing address:
  • Phone: 956-431-0056
  • Fax: 832-553-7287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number19-107154
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: