Provider Demographics
NPI:1477629558
Name:DOMINGO, ROBERT (PHD CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:PHD CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-1603
Mailing Address - Country:US
Mailing Address - Phone:631-293-5464
Mailing Address - Fax:
Practice Address - Street 1:399 CONKLIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2614
Practice Address - Country:US
Practice Address - Phone:516-249-5477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003834-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist