Provider Demographics
NPI:1407807837
Name:SOUTH, DOMENICA A (LCSW)
Entity Type:Individual
Prefix:
First Name:DOMENICA
Middle Name:A
Last Name:SOUTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 DAYTON LN
Mailing Address - Street 2:ANDRUS CHILDREN'S CENTER
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2859
Mailing Address - Country:US
Mailing Address - Phone:914-732-3371
Mailing Address - Fax:917-732-3372
Practice Address - Street 1:50 DAYTON LN
Practice Address - Street 2:ANDRUS CHILDREN'S CENTER MENTAL HEALTH DIVISION
Practice Address - City:PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10566-2859
Practice Address - Country:US
Practice Address - Phone:914-736-3371
Practice Address - Fax:914-736-3372
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067024104100000X
NY0760201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00076020Medicaid
NYN8745VE061Medicare PIN