Provider Demographics
NPI:1053142927
Name:WINN, DERIVIA
Entity type:Individual
Prefix:
First Name:DERIVIA
Middle Name:
Last Name:WINN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7636 E SHORE DR
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34450-5088
Mailing Address - Country:US
Mailing Address - Phone:706-351-0574
Mailing Address - Fax:
Practice Address - Street 1:4015 CRESCENT PARK DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3605
Practice Address - Country:US
Practice Address - Phone:813-492-8310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-368696106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician