Provider Demographics
NPI:1689261653
Name:THOM-ROGERS, CANDACE CHERILYN (MA, LAC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:CHERILYN
Last Name:THOM-ROGERS
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MAPLE AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4514
Mailing Address - Country:US
Mailing Address - Phone:646-732-8393
Mailing Address - Fax:
Practice Address - Street 1:111 DUNNELL RD STE 201
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-2634
Practice Address - Country:US
Practice Address - Phone:646-732-8393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00554900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health