Provider Demographics
NPI:1518614593
Name:PLUMMER, ISAAC HENRY JR
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:HENRY
Last Name:PLUMMER
Suffix:JR
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 1:296 S FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-3702
Mailing Address - Country:US
Mailing Address - Phone:850-333-1279
Mailing Address - Fax:850-634-6079
Practice Address - Street 1:296 S FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3702
Practice Address - Country:US
Practice Address - Phone:850-333-1279
Practice Address - Fax:850-634-6079
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-206086106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician