Provider Demographics
NPI:1457013823
Name:NORVILUS, DJENNIE
Entity Type:Individual
Prefix:
First Name:DJENNIE
Middle Name:
Last Name:NORVILUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10907 NW 9TH CT
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-7335
Mailing Address - Country:US
Mailing Address - Phone:239-785-4288
Mailing Address - Fax:
Practice Address - Street 1:10907 NW 9TH CT
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-7335
Practice Address - Country:US
Practice Address - Phone:239-785-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-164929106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110197500Medicaid