MEDICARE: DEON DERBY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1639580681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEON DERBY

Provider Business Mailing Address
First Line	:	5575 SIMMONS ST
Second Line	:	#1-363
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-9009
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3105 COLEMAN ST
Second Line	:	#B
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-3807
Country	:	US
Telephone Number	:	702-202-2567
Fax Number	:	800-783-8279

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2014
Last Update Date	:	05/13/2014

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Directions to “ DEON DERBY ” Practice Location

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