Provider Demographics
NPI:1831518950
Name:DOMENECH, ANGELA (MSED)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:DOMENECH
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 1:9 MEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-2921
Mailing Address - Country:US
Mailing Address - Phone:347-461-1289
Mailing Address - Fax:
Practice Address - Street 1:9 MEDFORD RD
Practice Address - Street 2:
Practice Address - City:SOUND BEACH
Practice Address - State:NY
Practice Address - Zip Code:11789-2921
Practice Address - Country:US
Practice Address - Phone:347-461-1289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY835367141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist