Provider Demographics
NPI:1093496416
Name:DECARLO, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:DECARLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SHERIDAN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2626
Mailing Address - Country:US
Mailing Address - Phone:914-552-7144
Mailing Address - Fax:
Practice Address - Street 1:535 OCEAN AVE STE 4
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4970
Practice Address - Country:US
Practice Address - Phone:207-370-5389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC222831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical