Provider Demographics
NPI:1780670612
Name:CANDIDO, DOMINIC ANTHONY (PHD)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:ANTHONY
Last Name:CANDIDO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:DOMINIC
Other - Middle Name:ANTHONY
Other - Last Name:CANDIDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:67 ETNA ROAD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766
Mailing Address - Country:US
Mailing Address - Phone:603-448-0055
Mailing Address - Fax:603-727-9042
Practice Address - Street 1:67 ETNA ROAD
Practice Address - Street 2:SUITE 350
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766
Practice Address - Country:US
Practice Address - Phone:603-448-0055
Practice Address - Fax:603-727-9042
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY10699103TC0700X
NHNH 1126103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV96141Medicare ID - Type Unspecified
NYAC00193OtherMDNY