MEDICARE: DECLARE THERAPY CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982962437
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DECLARE THERAPY CENTER, INC.

Provider Business Mailing Address
First Line	:	635 W 7TH ST STE 103
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45203-1546
Country	:	US
Telephone Number	:	513-834-7050
Fax Number	:	513-834-7052

Provider Business Practice Location Address
First Line	:	635 W 7TH ST STE 103
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45203-1546
Country	:	US
Telephone Number	:	513-834-7050
Fax Number	:	513-834-7052

Authorized Official
Title or Position	:	CEO
Name	:	PURCELL TAYLOR JR.
Credential	:	LPCC-S, LICDC-S, ED.
Telephone Number	:	513-834-7050

Provider Enumeration Date	:	05/02/2012
Last Update Date	:	07/21/2022

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