Healthcare Provider Details

I. General information

NPI: 1538206735
Provider Name (Legal Business Name): JEROME PREZZY MASTER'S OF ARTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 FOREST DR SUITE 114A
COLUMBIA SC
29204-2379
US

IV. Provider business mailing address

2611 FOREST DR SUITE 114A
COLUMBIA SC
29204-2379
US

V. Phone/Fax

Practice location:
  • Phone: 803-799-0144
  • Fax: 803-799-1136
Mailing address:
  • Phone: 803-799-0144
  • Fax: 803-799-1136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberMRW054
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: