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General NPI Number Information
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NPI Number | 1285877795
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Entity Type | Organization
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Legal Business Name | ANGELO S DOMINGO JR LLC
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Dates
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Enumeration Date | 04/14/2009
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Last Update Date | 04/14/2009
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Provider Practice Location Address
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Address Line | 9926 52ND ST E
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City | PARRISH
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State | FL
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Zip | 34219-4417
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Country | US
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Telephone | 203-668-6318
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Fax |
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Provider Business Mailing Address
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Address Line | 9926 52ND ST E
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City | PARRISH
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State | FL
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Zip | 34219-4417
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Country | US
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Telephone | 203-668-6318
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. ANGELO S DOMINGO JR.
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Credential | PSYD
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Telephone | 203-668-6318
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY7379
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License Number State | FL
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