Provider Demographics
NPI:1679591630
Name:DIDOMENICO, DOREEN M (PHD)
Entity type:Individual
Prefix:DR
First Name:DOREEN
Middle Name:M
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-2823
Mailing Address - Country:US
Mailing Address - Phone:201-362-3741
Mailing Address - Fax:
Practice Address - Street 1:597 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-4503
Practice Address - Country:US
Practice Address - Phone:201-362-3741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00364600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical