Basic Information
| Provider Information | |||||||||
| NPI: | 1871602656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECLUE | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3413 STATE HIGHWAY 8 | ||||||||
| Address2: | |||||||||
| City: | SOUTH NEW BERLIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138432120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6078592231 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 NOYES STREET | ||||||||
| Address2: | MOHAWK VALLEY PSYCHIATRIC CENTER- YORK STREET CLINIC | ||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157382660 | ||||||||
| FaxNumber: | 3157384410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 067256 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 075896 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 713667 | 01 | NY | MVP MOHAWK VALLEY PLAN | OTHER |