=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457851792
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLEY TRILLOW LSW , MSW, LICDC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2018
-----------------------------------------------------
Last Update Date | 06/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 NOBLE DR
-----------------------------------------------------
City | WOOSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44691-5353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-264-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 NOBLE DR
-----------------------------------------------------
City | WOOSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44691-5353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-264-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | S.1903309
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 164574
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 1903309
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------