MEDICARE: DEREK MOSKOWITZ

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1760114060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK MOSKOWITZ

Provider Business Mailing Address
First Line	:	1944 E 4TH ST APT 1
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-3867
Country	:	US
Telephone Number	:	949-793-5954
Fax Number	:

Provider Business Practice Location Address
First Line	:	1944 E 4TH ST APT 1
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-3867
Country	:	US
Telephone Number	:	949-793-5954
Fax Number	:

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

Provider Enumeration Date	:	06/27/2022
Last Update Date	:	06/27/2022

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