Provider Demographics
NPI:1003951344
Name:DOMINGO, ANGELO SEBASTIAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANGELO
Middle Name:SEBASTIAN
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:941-822-6122
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:941-822-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7379103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA931OtherMEDICARE PTAN