Provider Demographics
NPI:1538206735
Name:PREZZY, JEROME (MASTER'S OF ARTS)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:PREZZY
Suffix:
Gender:M
Credentials:MASTER'S OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 FOREST DR
Mailing Address - Street 2:SUITE 114A
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2379
Mailing Address - Country:US
Mailing Address - Phone:803-799-0144
Mailing Address - Fax:803-799-1136
Practice Address - Street 1:2611 FOREST DR
Practice Address - Street 2:SUITE 114A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2379
Practice Address - Country:US
Practice Address - Phone:803-799-0144
Practice Address - Fax:803-799-1136
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMRW054103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCWP9902Medicaid