1922241413 NPI number — MRS. M. KEELY ROSEDALE DEKER M.S., BCBA

Table of content: MRS. M. KEELY ROSEDALE DEKER M.S., BCBA (NPI 1922241413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922241413 NPI number — MRS. M. KEELY ROSEDALE DEKER M.S., BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEKER
Provider First Name:
M. KEELY
Provider Middle Name:
ROSEDALE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSEDALE DEKER
Provider Other First Name:
MEREDITH
Provider Other Middle Name:
KEELY
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S., BCBA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1922241413
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4512 BRIDGEWATER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32817-1373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-295-0189
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
848 EXECUTIVE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OVIEDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32765-7699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-678-8889
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-02-0847 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111554900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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