Provider Demographics
NPI:1710416334
Name:DIMAGGIO, DOMINIC (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:
Last Name:DIMAGGIO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2456 BROADWAY FL 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2022
Mailing Address - Country:US
Mailing Address - Phone:810-923-8673
Mailing Address - Fax:848-216-1915
Practice Address - Street 1:2456 BROADWAY FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2022
Practice Address - Country:US
Practice Address - Phone:810-923-8673
Practice Address - Fax:848-216-1915
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33629103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health