Provider Demographics
NPI:1770190043
Name:DOMINIQUE, CARLAH (LCADC)
Entity Type:Individual
Prefix:
First Name:CARLAH
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 RENAISSANCE BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2781
Mailing Address - Country:US
Mailing Address - Phone:484-803-9663
Mailing Address - Fax:484-393-4096
Practice Address - Street 1:670 ROUTE 1 N
Practice Address - Street 2:
Practice Address - City:ISELIN
Practice Address - State:NJ
Practice Address - Zip Code:08830-2629
Practice Address - Country:US
Practice Address - Phone:732-510-1140
Practice Address - Fax:732-218-9749
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00320100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)