Healthcare Provider Details

I. General information

NPI: 1477444735
Provider Name (Legal Business Name): DEANGELO DERRICK BAILEY II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5949 HARBOUR PARK DR
MIDLOTHIAN VA
23112-2163
US

IV. Provider business mailing address

1500 S DOUGLAS RD STE 230
CORAL GABLES FL
33134-4108
US

V. Phone/Fax

Practice location:
  • Phone: 757-537-0704
  • Fax:
Mailing address:
  • Phone: 844-244-1818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberA61672242
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: