Provider Demographics
NPI:1285877795
Name:ANGELO S DOMINGO JR LLC
Entity type:Organization
Organization Name:ANGELO S DOMINGO JR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOMINGO
Authorized Official - Suffix:JR
Authorized Official - Credentials:PSYD
Authorized Official - Phone:203-668-6318
Mailing Address - Street 1:9926 52ND ST E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-4417
Mailing Address - Country:US
Mailing Address - Phone:203-668-6318
Mailing Address - Fax:
Practice Address - Street 1:9926 52ND ST E
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-4417
Practice Address - Country:US
Practice Address - Phone:203-668-6318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7379103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty