Provider Demographics
NPI:1689484750
Name:CARBON, DOMINIQUE
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:CARBON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 PUTNAM DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-5165
Mailing Address - Country:US
Mailing Address - Phone:516-492-9103
Mailing Address - Fax:
Practice Address - Street 1:173 PUTNAM DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-5165
Practice Address - Country:US
Practice Address - Phone:516-492-9103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool