Provider Demographics
NPI:1740053917
Name:DERISO, NICOLE RENEE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:DERISO
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 1:1408 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-4020
Mailing Address - Country:US
Mailing Address - Phone:352-373-4411
Mailing Address - Fax:352-373-4455
Practice Address - Street 1:1200 CONCORD AVE # 185
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4915
Practice Address - Country:US
Practice Address - Phone:877-910-6538
Practice Address - Fax:352-373-4455
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician