Provider Demographics
NPI:1871602656
Name:DECLUE, CAROL (LMSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:DECLUE
Suffix:
Gender:F
Credentials:LMSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 STATE HIGHWAY 8
Mailing Address - Street 2:
Mailing Address - City:SOUTH NEW BERLIN
Mailing Address - State:NY
Mailing Address - Zip Code:13843-2120
Mailing Address - Country:US
Mailing Address - Phone:607-859-2231
Mailing Address - Fax:
Practice Address - Street 1:1400 NOYES STREET
Practice Address - Street 2:MOHAWK VALLEY PSYCHIATRIC CENTER- YORK STREET CLINIC
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-738-2660
Practice Address - Fax:315-738-4410
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0672561041C0700X
NY0758961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY713667OtherMVP MOHAWK VALLEY PLAN