Provider Demographics
NPI:1366823445
Name:DIDOMENICO, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:DIDOMENICO
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 1:133 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ESTELL MANOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08319-1716
Mailing Address - Country:US
Mailing Address - Phone:609-501-3466
Mailing Address - Fax:609-939-0220
Practice Address - Street 1:133 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:ESTELL MANOR
Practice Address - State:NJ
Practice Address - Zip Code:08319-1716
Practice Address - Country:US
Practice Address - Phone:609-501-3466
Practice Address - Fax:609-939-0220
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00848100225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist