Provider Demographics
NPI:1053840843
Name:DECKER, BRIAN (LMHC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:DECKER
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 DAWES AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-1637
Mailing Address - Country:US
Mailing Address - Phone:845-536-9113
Mailing Address - Fax:
Practice Address - Street 1:114 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3508
Practice Address - Country:US
Practice Address - Phone:845-536-9113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007942101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1336163963Medicaid