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	101YA0400X	Addiction (Substance Use Disorder) Counselor	85387	OH
2	251S00000X	Community/Behavioral Health Agency	E0000656, 85387	OH

General Provider Information

NPI Number	:	1063652527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DECLARE THERAPY CENTER INC

Provider Business Mailing Address
First Line	:	700 W PETE ROSE WAY STE 456
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45203-1875
Country	:	US
Telephone Number	:	513-834-7050
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 W PETE ROSE WAY
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45203-1892
Country	:	US
Telephone Number	:	513-290-7908
Fax Number	:	513-834-7052

Authorized Official
Title or Position	:	PRESIDENT CEO
Name	:	DR. PURCELL TAYLOR JR.
Credential	:	ED.D.
Telephone Number	:	513-290-7908

Provider Enumeration Date	:	02/24/2009
Last Update Date	:	01/19/2012

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