Provider Demographics
NPI:1619495595
Name:DECIUS, GERTRUDE (RBT)
Entity Type:Individual
Prefix:MRS
First Name:GERTRUDE
Middle Name:
Last Name:DECIUS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 NW 36TH ST APT 305
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-6444
Mailing Address - Country:US
Mailing Address - Phone:954-588-8961
Mailing Address - Fax:
Practice Address - Street 1:1001 W CYPRESS CREEK RD STE 120
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1947
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD220-280-84-567-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$OtherMEDWAIVER