Provider Demographics
NPI:1942841465
Name:FOCAZIO-MARRA, DOMINIQUE ANN (LSW)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:ANN
Last Name:FOCAZIO-MARRA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:A
Other - Last Name:FOCAZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:579 W CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07401-1916
Mailing Address - Country:US
Mailing Address - Phone:646-637-4201
Mailing Address - Fax:
Practice Address - Street 1:17 S FRANKLIN TPKE
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-2552
Practice Address - Country:US
Practice Address - Phone:646-637-4201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-06
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL064516001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical