Provider Demographics
NPI:1710172457
Name:DECARLIS, JOHN RICHARD (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RICHARD
Last Name:DECARLIS
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10411 W 145TH TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-2550
Mailing Address - Country:US
Mailing Address - Phone:913-499-8096
Mailing Address - Fax:
Practice Address - Street 1:10411 W 145TH TER
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66221-2550
Practice Address - Country:US
Practice Address - Phone:913-499-8096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD131151041C0700X
MO20100382591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1710172457Medicaid
MO1710172457Medicaid