Provider Demographics
NPI:1508293291
Name:DOMIANO, LINDA S (LISAC)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:S
Last Name:DOMIANO
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 S MACDONALD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-1310
Mailing Address - Country:US
Mailing Address - Phone:480-969-1471
Mailing Address - Fax:480-264-0687
Practice Address - Street 1:32 S MACDONALD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-1310
Practice Address - Country:US
Practice Address - Phone:480-969-1471
Practice Address - Fax:480-264-0687
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10774101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)