Provider Demographics
NPI:1063938223
Name:DERICO, CHRISTINE' L
Entity type:Individual
Prefix:
First Name:CHRISTINE'
Middle Name:L
Last Name:DERICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 SW 18TH ST
Mailing Address - Street 2:
Mailing Address - City:N LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-5210
Mailing Address - Country:US
Mailing Address - Phone:305-709-7777
Mailing Address - Fax:
Practice Address - Street 1:6610 SW 18TH ST
Practice Address - Street 2:
Practice Address - City:N LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-5210
Practice Address - Country:US
Practice Address - Phone:305-709-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst