Provider Demographics
NPI:1235662420
Name:PISANA, DEREK WILLIAM
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:WILLIAM
Last Name:PISANA
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 1:2073 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3243
Mailing Address - Country:US
Mailing Address - Phone:321-888-3020
Mailing Address - Fax:661-263-4584
Practice Address - Street 1:2073 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3243
Practice Address - Country:US
Practice Address - Phone:321-888-3020
Practice Address - Fax:661-263-4584
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-41888106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician