Provider Demographics
NPI:1417281890
Name:CAGLIOSTRO, DOMINIC JOHN (LCSW, LADAC)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JOHN
Last Name:CAGLIOSTRO
Suffix:
Gender:M
Credentials:LCSW, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 QUINCY ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1257
Mailing Address - Country:US
Mailing Address - Phone:505-550-1306
Mailing Address - Fax:844-434-8055
Practice Address - Street 1:146 QUINCY ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1257
Practice Address - Country:US
Practice Address - Phone:505-550-1306
Practice Address - Fax:844-434-8055
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-09928101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM19983085Medicaid