Provider Demographics
NPI:1972173532
Name:PEZZELLA, STEPHANIE DANIELLA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DANIELLA
Last Name:PEZZELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 NICHOLSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2122
Mailing Address - Country:US
Mailing Address - Phone:704-907-8177
Mailing Address - Fax:
Practice Address - Street 1:1547 CHERRY RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2616
Practice Address - Country:US
Practice Address - Phone:704-907-8177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-19-96067106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician