=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639389737
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUIS A. DECOLA JR. PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 05/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 779 GARRISON RD
-----------------------------------------------------
City | ASHTABULA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44004-9339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-709-6439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 779 GARRISON RD
-----------------------------------------------------
City | ASHTABULA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44004-9339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-998-4264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 4746
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------