Provider Demographics
NPI:1083083281
Name:DECARLO, COCO (08-30-16)
Entity Type:Individual
Prefix:
First Name:COCO
Middle Name:
Last Name:DECARLO
Suffix:
Gender:F
Credentials:08-30-16
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1666
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-1666
Mailing Address - Country:US
Mailing Address - Phone:530-333-9460
Mailing Address - Fax:
Practice Address - Street 1:5607 MOUNT MURPHY RD
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95633
Practice Address - Country:US
Practice Address - Phone:530-333-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1213050915101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)