=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679847040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERRICK MATTHEW DOVER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2012
-----------------------------------------------------
Last Update Date | 03/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 S STEPHANIE ST APT 611
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89012-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-858-2443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 S STEPHANIE ST APT 611
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89012-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-858-2443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------