Provider Demographics
NPI:1083811749
Name:DECARLO, MARK S (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:DECARLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:586-541-3735
Practice Address - Street 1:12955 OLD MERIDIAN ST STE 101
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7100
Practice Address - Country:US
Practice Address - Phone:317-819-6600
Practice Address - Fax:317-819-6601
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN050018551225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist