Provider Demographics
NPI:1457842718
Name:D'AGOSTINO, DOMENIQUE DANA
Entity Type:Individual
Prefix:
First Name:DOMENIQUE
Middle Name:DANA
Last Name:D'AGOSTINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 MARINA CIR
Mailing Address - Street 2:
Mailing Address - City:DISCOVERY BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94505-9482
Mailing Address - Country:US
Mailing Address - Phone:925-813-5002
Mailing Address - Fax:
Practice Address - Street 1:1239 MARINA CIR
Practice Address - Street 2:
Practice Address - City:DISCOVERY BAY
Practice Address - State:CA
Practice Address - Zip Code:94505-9482
Practice Address - Country:US
Practice Address - Phone:925-529-7722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician