Provider Demographics
NPI:1124510060
Name:GRESOCK, DANA
Entity type:Individual
Prefix:MISS
First Name:DANA
Middle Name:
Last Name:GRESOCK
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 1:8562 BOWDEN WAY
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5308
Mailing Address - Country:US
Mailing Address - Phone:734-731-6221
Mailing Address - Fax:
Practice Address - Street 1:907 OUTER RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6601
Practice Address - Country:US
Practice Address - Phone:407-217-1401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-305008106S00000X
103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service