Provider Demographics
NPI:1851924641
Name:DOMINGUEZ, DIEGO LEONARDO
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:LEONARDO
Last Name:DOMINGUEZ
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 1:15 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:BELCHERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01007-9717
Mailing Address - Country:US
Mailing Address - Phone:413-687-1539
Mailing Address - Fax:
Practice Address - Street 1:249 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01013-1679
Practice Address - Country:US
Practice Address - Phone:413-540-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health