Provider Demographics
NPI:1659977965
Name:WASHINGTON, DOMONICK
Entity Type:Individual
Prefix:
First Name:DOMONICK
Middle Name:
Last Name:WASHINGTON
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 1:1120 E LANCASTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-2754
Mailing Address - Country:US
Mailing Address - Phone:132-386-7227
Mailing Address - Fax:
Practice Address - Street 1:23502 LYONS AVE STE 304A
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91321-2538
Practice Address - Country:US
Practice Address - Phone:661-702-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician