Provider Demographics
NPI:1649340134
Name:DOMINGO, ROXANNE M (PSYD)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:M
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LINDEN BLVD
Mailing Address - Street 2:F3
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-3498
Mailing Address - Country:US
Mailing Address - Phone:718-282-7946
Mailing Address - Fax:
Practice Address - Street 1:1745 BROADWAY
Practice Address - Street 2:17 FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4640
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:212-537-0102
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16367103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02824404Medicaid
NYVB1231Medicare PIN
NY02824404Medicaid