Provider Demographics
NPI:1134376882
Name:MASTRODOMENICO, AMALIA (AODC)
Entity type:Individual
Prefix:MRS
First Name:AMALIA
Middle Name:
Last Name:MASTRODOMENICO
Suffix:
Gender:F
Credentials:AODC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6254 TAMPA AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6643
Mailing Address - Country:US
Mailing Address - Phone:818-593-9589
Mailing Address - Fax:
Practice Address - Street 1:6580 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1426
Practice Address - Country:US
Practice Address - Phone:818-908-1740
Practice Address - Fax:818-908-3336
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)