Provider Demographics
NPI:1427544501
Name:ROBERTS, DERRICK (BCBA)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11302 FORESTDALE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-3779
Mailing Address - Country:US
Mailing Address - Phone:904-887-8811
Mailing Address - Fax:
Practice Address - Street 1:11302 FORESTDALE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218
Practice Address - Country:US
Practice Address - Phone:904-887-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18-57130106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician