Provider Demographics
NPI:1598283087
Name:DOMINO, TERRY (CSW, MLA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:DOMINO
Suffix:
Gender:F
Credentials:CSW, MLA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 S I 10 SERVICE RD W STE 215
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-7436
Mailing Address - Country:US
Mailing Address - Phone:504-301-9990
Mailing Address - Fax:
Practice Address - Street 1:4300 S I 10 SERVICE RD W STE 215
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-7436
Practice Address - Country:US
Practice Address - Phone:504-301-9990
Practice Address - Fax:504-301-9990
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13761104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13761OtherCSW