Healthcare Provider Details

I. General information

NPI: 1780670612
Provider Name (Legal Business Name): DOMINIC ANTHONY CANDIDO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DOMINIC ANTHONY CANDIDO PHD

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 ETNA ROAD SUITE 350
LEBANON NH
03766
US

IV. Provider business mailing address

67 ETNA ROAD SUITE 350
LEBANON NH
03766
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-0055
  • Fax: 603-727-9042
Mailing address:
  • Phone: 603-448-0055
  • Fax: 603-727-9042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberNY10699
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberNH 1126
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: