Provider Demographics
NPI:1255481735
Name:CARNUCCIO, DOMENIC JOHN (MA, NCC, LPC)
Entity type:Individual
Prefix:MR
First Name:DOMENIC
Middle Name:JOHN
Last Name:CARNUCCIO
Suffix:
Gender:M
Credentials:MA, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:316 TASHA LN
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-4260
Mailing Address - Country:US
Mailing Address - Phone:610-466-9693
Mailing Address - Fax:610-431-2045
Practice Address - Street 1:440 E MARSHALL ST STE 100
Practice Address - Street 2:EAST MARSHALL STREET MEDICAL CAMPUS
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-5414
Practice Address - Country:US
Practice Address - Phone:610-431-2044
Practice Address - Fax:610-431-2045
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAPC004241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional