Provider Demographics
NPI:1366156804
Name:ALDERMAN, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ALDERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 WALTERS PL
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-5132
Mailing Address - Country:US
Mailing Address - Phone:352-431-0100
Mailing Address - Fax:
Practice Address - Street 1:415 WALTERS PL
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-5132
Practice Address - Country:US
Practice Address - Phone:352-431-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-7271-396892106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBACB728284Medicaid