Provider Demographics
NPI:1609236744
Name:IMPLICITO, CARLEEN (LAC)
Entity Type:Individual
Prefix:
First Name:CARLEEN
Middle Name:
Last Name:IMPLICITO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07642-2820
Mailing Address - Country:US
Mailing Address - Phone:201-722-9476
Mailing Address - Fax:
Practice Address - Street 1:113 W ESSEX ST
Practice Address - Street 2:SUITE 203
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1023
Practice Address - Country:US
Practice Address - Phone:201-661-0595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00115500171100000X
NY005668171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist