Provider Demographics
NPI:1447056676
Name:DOMICCIO, TIMOTHY CAGE
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:CAGE
Last Name:DOMICCIO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S INDIAN HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-5444
Mailing Address - Country:US
Mailing Address - Phone:909-476-2023
Mailing Address - Fax:
Practice Address - Street 1:650 S INDIAN HILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-5444
Practice Address - Country:US
Practice Address - Phone:909-476-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1594370125101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)