Provider Demographics
NPI:1114268836
Name:DOMINIC, JOHNY (MA)
Entity Type:Individual
Prefix:
First Name:JOHNY
Middle Name:
Last Name:DOMINIC
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 E 43RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-4007
Mailing Address - Country:US
Mailing Address - Phone:516-637-1619
Mailing Address - Fax:212-370-5791
Practice Address - Street 1:250 W 57TH ST
Practice Address - Street 2:SUITE 501 NATIONAL INSTITUTE FOR PSYCHOTHERAPIES
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10107-0001
Practice Address - Country:US
Practice Address - Phone:212-582-1566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP79437101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral