Provider Demographics
NPI:1801560172
Name:DECENZO, GABRIELLA MARIE
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:MARIE
Last Name:DECENZO
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 1:7308 BROOKSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8169
Mailing Address - Country:US
Mailing Address - Phone:843-602-6601
Mailing Address - Fax:
Practice Address - Street 1:7308 BROOKSTONE WAY
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-8169
Practice Address - Country:US
Practice Address - Phone:843-602-6601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC301805103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZCS61339471OtherBCBS SC