Provider Demographics
NPI:1487024006
Name:DECLERCK, DANIEL J (LMHC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:DECLERCK
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 CURRAN RD
Mailing Address - Street 2:
Mailing Address - City:SHORTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14548-9333
Mailing Address - Country:US
Mailing Address - Phone:315-521-4033
Mailing Address - Fax:
Practice Address - Street 1:443 CURRAN RD
Practice Address - Street 2:
Practice Address - City:SHORTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14548-9333
Practice Address - Country:US
Practice Address - Phone:315-521-4033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-26
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005883101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health