Provider Demographics
NPI:1386809580
Name:DECOLA, MICHELLE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:DECOLA
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 1:638 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1620
Mailing Address - Country:US
Mailing Address - Phone:773-497-7090
Mailing Address - Fax:
Practice Address - Street 1:875 N DEARBORN ST STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-3397
Practice Address - Country:US
Practice Address - Phone:312-458-0646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180002541101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205565871OtherEMPLOYER IDENTIFICATION NUMBER