=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427614312
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERECK HOUSEHOLDER RBT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2019
-----------------------------------------------------
Last Update Date | 05/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2643 LOWELL CIR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-2216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-330-7126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2643 LOWELL CIR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-2216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-330-7126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-18-69317
-----------------------------------------------------
License Number State |
-----------------------------------------------------