Provider Demographics
NPI:1427069251
Name:DECKER, BRENT (PHD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:DECKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W 23RD ST BLDG D1
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4553
Mailing Address - Country:US
Mailing Address - Phone:850-522-9456
Mailing Address - Fax:850-522-9094
Practice Address - Street 1:11 W 23RD ST BLDG D1
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4553
Practice Address - Country:US
Practice Address - Phone:850-522-9456
Practice Address - Fax:850-522-9094
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5989103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54477OtherBC/BS OF FLORIDA
FL54477OtherBC/BS OF FLORIDA
FLS80457Medicare UPIN