Provider Demographics
NPI:1699368050
Name:DEZELL, GREGORY (LCSW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:DEZELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N MIDVALE BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3265
Mailing Address - Country:US
Mailing Address - Phone:608-852-8601
Mailing Address - Fax:
Practice Address - Street 1:1190 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2044
Practice Address - Country:US
Practice Address - Phone:608-370-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9553-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical