Provider Demographics
NPI:1841669215
Name:LADA, KIMBERLY (LAC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LADA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:SANTO DOMINGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:160 ATLANTIC CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08721-1229
Mailing Address - Country:US
Mailing Address - Phone:732-349-5550
Mailing Address - Fax:
Practice Address - Street 1:160 ATLANTIC CITY BLVD
Practice Address - Street 2:
Practice Address - City:BAYVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08721-1229
Practice Address - Country:US
Practice Address - Phone:732-349-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00183300101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor