Provider Demographics
NPI:1407945868
Name:DOMENICO, RAYMOND ANTHONY (PHD, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:ANTHONY
Last Name:DOMENICO
Suffix:
Gender:M
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:47 COGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2533
Mailing Address - Country:US
Mailing Address - Phone:518-561-7882
Mailing Address - Fax:
Practice Address - Street 1:101 BROAD ST
Practice Address - Street 2:224 SIBLEY HALL
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2637
Practice Address - Country:US
Practice Address - Phone:518-564-2170
Practice Address - Fax:518-564-5110
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000269-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist