Provider Demographics
NPI:1386359776
Name:TELLEZ, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:TELLEZ
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 1:102 BOWIE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-6036
Mailing Address - Country:US
Mailing Address - Phone:863-234-7182
Mailing Address - Fax:
Practice Address - Street 1:1532 SW MAPP RD
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-2446
Practice Address - Country:US
Practice Address - Phone:772-678-6704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-22-224349106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117225800Medicaid