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General NPI Number Information
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NPI Number | 1033626437
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Entity Type | Individual
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Provider Name | TAYLOR DETHEROW
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Gender | Male
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Dates
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Enumeration Date | 01/07/2018
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Last Update Date | 11/01/2020
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Provider Practice Location Address
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Address Line | 3771 STEFANI RD
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City | CANTONMENT
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State | FL
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Zip | 32533-7795
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Country | US
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Telephone | 850-607-6910
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Fax | 850-607-6932
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Provider Business Mailing Address
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Address Line | 1007 PINEVIEW BLVD UNIT C
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1499
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Country | US
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Telephone | 925-337-7384
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106E00000X
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Taxonomy Name | Assistant Behavior Analyst
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License Number | 10190
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | 35476
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-20-45584
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License Number State | FL
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