Provider Demographics
NPI:1871043430
Name:DICARLO, VINCENT
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:DICARLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2292 LESPERANCE ROAD
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N8N 2W4
Mailing Address - Country:CA
Mailing Address - Phone:519-979-8190
Mailing Address - Fax:
Practice Address - Street 1:26184 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2084
Practice Address - Country:US
Practice Address - Phone:313-389-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010997451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical