Healthcare Provider Details

I. General information

NPI: 1770190043
Provider Name (Legal Business Name): CARLAH DOMINIQUE LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 ROUTE 1 N
ISELIN NJ
08830-2629
US

IV. Provider business mailing address

2701 RENAISSANCE BLVD FL 4
KING OF PRUSSIA PA
19406-2781
US

V. Phone/Fax

Practice location:
  • Phone: 732-510-1140
  • Fax: 732-218-9749
Mailing address:
  • Phone: 484-803-9663
  • Fax: 484-393-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00320100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: