Provider Demographics
NPI:1518552306
Name:DOMINO, ALICE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:DOMINO
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 1:38 HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-2039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 N TRAINOR AVE
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-3231
Practice Address - Country:US
Practice Address - Phone:631-878-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician