Provider Demographics
NPI:1992283162
Name:DIMAGGIO, ANTHONY JAMES (MFTI)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JAMES
Last Name:DIMAGGIO
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 S LUCERNE BLVD APT 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-4802
Mailing Address - Country:US
Mailing Address - Phone:818-640-0503
Mailing Address - Fax:
Practice Address - Street 1:3415 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-5405
Practice Address - Country:US
Practice Address - Phone:818-640-0503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94258106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist