Provider Demographics
NPI:1346480951
Name:DATLOF, IDELLE
Entity Type:Individual
Prefix:MS
First Name:IDELLE
Middle Name:
Last Name:DATLOF
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 1:6833 SPRINGCREST CIR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45243-2435
Mailing Address - Country:US
Mailing Address - Phone:513-793-4745
Mailing Address - Fax:
Practice Address - Street 1:420 W LOVELAND AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-2368
Practice Address - Country:US
Practice Address - Phone:513-300-0566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.09000341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical