Healthcare Provider Details

I. General information

NPI: 1861130205
Provider Name (Legal Business Name): JILLIAN A DECARLO CT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 05/25/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8411 BROADWAY AVE # 3932
CLEVELAND OH
44105-3932
US

IV. Provider business mailing address

4521 FRUITLAND DR
PARMA OH
44134-4534
US

V. Phone/Fax

Practice location:
  • Phone: 216-441-0200
  • Fax:
Mailing address:
  • Phone: 216-694-1285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC.2204010-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: