Provider Demographics
NPI:1962415463
Name:MOLINARI, DOMINICK J (PHD)
Entity type:Individual
Prefix:
First Name:DOMINICK
Middle Name:J
Last Name:MOLINARI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 JOHN ADAMS COURT
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-4604
Mailing Address - Country:US
Mailing Address - Phone:718-981-1397
Mailing Address - Fax:
Practice Address - Street 1:172 RAVENHURST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310
Practice Address - Country:US
Practice Address - Phone:718-981-1397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007056103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
139240OtherVALUE OPTIONS
0002697OtherGHI
NYS11900Medicare UPIN
0002697OtherGHI