Provider Demographics
NPI:1740717461
Name:DIDOMENICO, ELIZABETH MARY (MSED)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 W HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-6532
Mailing Address - Country:US
Mailing Address - Phone:631-617-2847
Mailing Address - Fax:
Practice Address - Street 1:16 W HAVEN DR
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-6532
Practice Address - Country:US
Practice Address - Phone:631-617-2847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician