Provider Demographics
NPI:1104797034
Name:SERRANO, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:SERRANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 MOUNTAIN FLOWER LN
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-4231
Mailing Address - Country:US
Mailing Address - Phone:352-777-3763
Mailing Address - Fax:
Practice Address - Street 1:1375 MOUNTAIN FLOWER LN
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-4231
Practice Address - Country:US
Practice Address - Phone:352-777-3763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLS652160994100106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty