Provider Demographics
NPI:1225742893
Name:DENEAUD, CARLY CHARLSON
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:CHARLSON
Last Name:DENEAUD
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 1:1203 IMPERIAL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33413-1081
Mailing Address - Country:US
Mailing Address - Phone:561-603-4618
Mailing Address - Fax:
Practice Address - Street 1:1203 IMPERIAL LAKE RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33413-1081
Practice Address - Country:US
Practice Address - Phone:561-603-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-248490106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician