Provider Demographics
NPI:1609533744
Name:DAMBROSIO, DOMINIC ANTHONY
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:ANTHONY
Last Name:DAMBROSIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 RISA RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3418
Mailing Address - Country:US
Mailing Address - Phone:925-284-1898
Mailing Address - Fax:
Practice Address - Street 1:954 RISA RD STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3418
Practice Address - Country:US
Practice Address - Phone:925-284-1898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27758106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist