Provider Demographics
NPI:1932485141
Name:BRENT DECKER, PH.D., PA
Entity Type:Organization
Organization Name:BRENT DECKER, PH.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P/V/S/T
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:850-522-9456
Mailing Address - Street 1:11 W 23RD ST
Mailing Address - Street 2:SUITE D1
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7603
Mailing Address - Country:US
Mailing Address - Phone:850-522-9456
Mailing Address - Fax:850-522-9094
Practice Address - Street 1:11 W 23RD ST
Practice Address - Street 2:SUITE D1
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7603
Practice Address - Country:US
Practice Address - Phone:850-522-9456
Practice Address - Fax:850-522-9094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5989103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS80457Medicare UPIN