Provider Demographics
NPI:1467060798
Name:DOMITROVICH, BRIAN LEE (SUDCC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:DOMITROVICH
Suffix:
Gender:F
Credentials:SUDCC
Other - Prefix:
Other - First Name:RAQUEL
Other - Middle Name:AMBER
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6649 FOOTHILL BLVD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2018
Mailing Address - Country:US
Mailing Address - Phone:415-318-0375
Mailing Address - Fax:
Practice Address - Street 1:2577 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1159
Practice Address - Country:US
Practice Address - Phone:510-466-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13534101YA0400X
CAR1432670621101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)