Provider Demographics
NPI:1366269698
Name:BILLETTA, DOMINIC
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:BILLETTA
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 1:453 VOLPE RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-2641
Mailing Address - Country:US
Mailing Address - Phone:610-772-4066
Mailing Address - Fax:
Practice Address - Street 1:170 N HENDERSON RD STE 200
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-4422
Practice Address - Country:US
Practice Address - Phone:856-346-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH007258103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst