Basic Information
| Provider Information | |||||||||
| NPI: | 1619202413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECARLO | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | |||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 NEW SALEM RD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | UNIONTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 154018936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244370729 | ||||||||
| FaxNumber: | 7244372761 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 NEW SALEM RD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | UNIONTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 154018936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244370729 | ||||||||
| FaxNumber: | 7244372761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2009 | ||||||||
| LastUpdateDate: | 10/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.