Provider Demographics
NPI:1649923442
Name:DEDOMINICI, PETER (LSW)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:DEDOMINICI
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3095
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-0046
Mailing Address - Country:US
Mailing Address - Phone:937-754-5911
Mailing Address - Fax:999-999-9999
Practice Address - Street 1:188 W HEBBLE AVE
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-4960
Practice Address - Country:US
Practice Address - Phone:937-754-5911
Practice Address - Fax:999-999-9999
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0029122104100000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker