Healthcare Provider Details

I. General information

NPI: 1164045183
Provider Name (Legal Business Name): DOMINIC PHILIP TANNOIA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 WISCONSIN AVE NW
WASHINGTON DC
20015-2014
US

IV. Provider business mailing address

3302 LANCER PL
HYATTSVILLE MD
20782-3153
US

V. Phone/Fax

Practice location:
  • Phone: 202-363-1010
  • Fax:
Mailing address:
  • Phone: 207-749-5666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number06643
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: