Provider Demographics
NPI:1992404586
Name:ALFONSO, DEREK ABEY
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:ABEY
Last Name:ALFONSO
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 1:19721 SW 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8902
Mailing Address - Country:US
Mailing Address - Phone:786-773-4055
Mailing Address - Fax:
Practice Address - Street 1:19721 SW 89TH AVE
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-8902
Practice Address - Country:US
Practice Address - Phone:786-773-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-122219106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician