Provider Demographics
NPI:1760659247
Name:DOMINO, JUNE M
Entity Type:Individual
Prefix:
First Name:JUNE
Middle Name:M
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 1:6121 N THESTA ST STE 305
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8603
Mailing Address - Country:US
Mailing Address - Phone:323-538-1727
Mailing Address - Fax:
Practice Address - Street 1:6121 N THESTA ST STE 305
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8603
Practice Address - Country:US
Practice Address - Phone:323-538-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB33138103T00000X
225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist