Provider Demographics
NPI:1487231510
Name:VOLLRATH, CARLEY
Entity type:Individual
Prefix:
First Name:CARLEY
Middle Name:
Last Name:VOLLRATH
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 1:6460 HARRISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7958
Mailing Address - Country:US
Mailing Address - Phone:513-941-4999
Mailing Address - Fax:513-694-0168
Practice Address - Street 1:6460 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-7957
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:513-694-0168
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.179001101YA0400X
OHCDCA.183019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0469261Medicaid