Provider Demographics
NPI:1053764688
Name:LUCIA, DOMINIC G (MA, EDD)
Entity type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:G
Last Name:LUCIA
Suffix:
Gender:M
Credentials:MA, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 EMPIRE INDUSTRIAL CT
Mailing Address - Street 2:SUITE 'C'
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1991
Mailing Address - Country:US
Mailing Address - Phone:707-548-3368
Mailing Address - Fax:707-843-7639
Practice Address - Street 1:1824 EMPIRE INDUSTRIAL CT
Practice Address - Street 2:SUITE 'C'
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1991
Practice Address - Country:US
Practice Address - Phone:707-548-3368
Practice Address - Fax:707-843-7639
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94022435103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical