Provider Demographics
NPI:1174078885
Name:DOMENICO, ANDREA R
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:DOMENICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CLEAR CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-8462
Mailing Address - Country:US
Mailing Address - Phone:603-793-8029
Mailing Address - Fax:
Practice Address - Street 1:1361 ELM ST STE 400
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1323
Practice Address - Country:US
Practice Address - Phone:603-232-6987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1205101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health