Provider Demographics
NPI:1336915321
Name:DETORRE, DOMINICK ANTHONY III (RBT)
Entity type:Individual
Prefix:
First Name:DOMINICK
Middle Name:ANTHONY
Last Name:DETORRE
Suffix:III
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2694 PELAGORNIS DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8806
Mailing Address - Country:US
Mailing Address - Phone:321-419-7526
Mailing Address - Fax:
Practice Address - Street 1:3880 CATALINA ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2211
Practice Address - Country:US
Practice Address - Phone:321-346-8450
Practice Address - Fax:321-249-1105
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-23-313700106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120549600Medicaid