Basic Information
| Provider Information | |||||||||
| NPI: | 1164842654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLIGAN | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 453 KING ST | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329227621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216335511 | ||||||||
| FaxNumber: | 2120874413 | ||||||||
| Practice Location | |||||||||
| Address1: | 453 KING ST | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329227621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216335511 | ||||||||
| FaxNumber: | 2120874413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2014 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-10252 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.