Provider Demographics
NPI:1790174852
Name:DECIERO, DANE
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:
Last Name:DECIERO
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 1:8509 FM 969, BUILDING 627
Mailing Address - Street 2:C/O KIPP AUSTIN COLLEGE PREP
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78724
Mailing Address - Country:US
Mailing Address - Phone:512-673-6102
Mailing Address - Fax:
Practice Address - Street 1:8509 FM 969, BUILDING 627
Practice Address - Street 2:C/O KIPP AUSTIN COLLEGE PREP
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78724
Practice Address - Country:US
Practice Address - Phone:512-673-6102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX554891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical