Provider Demographics
NPI:1619402187
Name:KUGEL, DERRICK MICHAEL
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:MICHAEL
Last Name:KUGEL
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 1:15004 TURTLE LAKE CT
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-7728
Mailing Address - Country:US
Mailing Address - Phone:813-728-4276
Mailing Address - Fax:
Practice Address - Street 1:15004 TURTLE LAKE CT
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-7728
Practice Address - Country:US
Practice Address - Phone:813-728-4276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLK240173944220106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician