Provider Demographics
NPI:1811555782
Name:CARTER, CECILIA DOMINIQUE (LPC)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:DOMINIQUE
Last Name:CARTER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1347 PARMER DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1966
Mailing Address - Country:US
Mailing Address - Phone:618-741-7653
Mailing Address - Fax:
Practice Address - Street 1:3751 PENNRIDGE DR STE 113
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-1244
Practice Address - Country:US
Practice Address - Phone:314-292-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016008366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional