=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619434685
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOODY DUBREUZE JR. RBT-19-78692
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2019
-----------------------------------------------------
Last Update Date | 12/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2615 FAIRWAYS DR
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33035-1173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-338-9567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8905 NW 28TH DR APT F
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-5281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-338-9567
-----------------------------------------------------
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-19-78692
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------