Healthcare Provider Details

I. General information

NPI: 1003922857
Provider Name (Legal Business Name): GINA RACHELE BRAZZLE LCSW, BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 VETERAN DR
PEARSALL TX
78061-6623
US

IV. Provider business mailing address

10231 KOTZEBUE ST
SAN ANTONIO TX
78217-4430
US

V. Phone/Fax

Practice location:
  • Phone: 210-366-0033
  • Fax: 210-579-8636
Mailing address:
  • Phone: 210-366-0033
  • Fax: 210-579-8636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number05504
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: