Provider Demographics
NPI:1033626437
Name:DETHEROW, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:DETHEROW
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 1:1007 PINEVIEW BLVD UNIT C
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1499
Mailing Address - Country:US
Mailing Address - Phone:925-337-7384
Mailing Address - Fax:
Practice Address - Street 1:3771 STEFANI RD
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-7795
Practice Address - Country:US
Practice Address - Phone:850-607-6910
Practice Address - Fax:850-607-6932
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-07
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10190106E00000X
FL35476106S00000X
FL1-20-45584103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician