Provider Demographics
NPI:1457518284
Name:CONWAY-CLOUGH, CAROL MARY (LCADC, CAC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:MARY
Last Name:CONWAY-CLOUGH
Suffix:
Gender:F
Credentials:LCADC, CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HALF MILE RD
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5695
Mailing Address - Country:US
Mailing Address - Phone:732-747-7734
Mailing Address - Fax:732-747-7734
Practice Address - Street 1:250 HALF MILE RD
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-5695
Practice Address - Country:US
Practice Address - Phone:732-747-7734
Practice Address - Fax:732-747-7734
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00030400101YA0400X, 102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst