Provider Demographics
NPI:1982323226
Name:LONGO, DOMINI (MA, AMFT)
Entity Type:Individual
Prefix:
First Name:DOMINI
Middle Name:
Last Name:LONGO
Suffix:
Gender:F
Credentials:MA, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N COLLEGE PARK DR APT L13
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-9439
Mailing Address - Country:US
Mailing Address - Phone:626-485-6257
Mailing Address - Fax:
Practice Address - Street 1:1940 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2148
Practice Address - Country:US
Practice Address - Phone:909-392-1344
Practice Address - Fax:909-392-1344
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131103106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist