Provider Demographics
NPI:1326369257
Name:GIRARD-DOMENA, RICHARD (LCSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GIRARD-DOMENA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 150
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:551 N COUNTRY RD
Practice Address - Street 2:STE 203
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-1445
Practice Address - Country:US
Practice Address - Phone:631-504-2102
Practice Address - Fax:631-686-5807
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1156181041C0700X
NY0789411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical