Provider Demographics
NPI:1649746900
Name:DI DOMENICO, CHRISTOPHER AVERY
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:AVERY
Last Name:DI DOMENICO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9851 FOLSOM BLVD APT A
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-1328
Mailing Address - Country:US
Mailing Address - Phone:208-515-9457
Mailing Address - Fax:
Practice Address - Street 1:NORTH SITE: 4441 AUBURN BLVD, SUITE E
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827
Practice Address - Country:US
Practice Address - Phone:916-473-5764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)