Provider Demographics
NPI:1679608103
Name:DOMENICO, EUGENE (PHD LCSW)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:
Last Name:DOMENICO
Suffix:
Gender:M
Credentials:PHD LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MARKET STREET
Mailing Address - Street 2:BEWLEY BUILDING SUITE #437
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094
Mailing Address - Country:US
Mailing Address - Phone:716-438-2436
Mailing Address - Fax:716-438-2435
Practice Address - Street 1:MARKET STREET
Practice Address - Street 2:BEWLEY BUILDING SUITE #437
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094
Practice Address - Country:US
Practice Address - Phone:716-438-2436
Practice Address - Fax:716-438-2435
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034738-1101YM0800X, 1041C0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00020255501OtherUNIVERA
NY000511600005OtherBCBS