Basic Information
| Provider Information | |||||||||
| NPI: | 1982323226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONGO | ||||||||
| FirstName: | DOMINI | ||||||||
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| Credential: | MA, AMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927053907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149898304 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4760 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902304820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103906612 | ||||||||
| FaxNumber: | 3103985690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2022 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 131103 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.