Provider Demographics
NPI:1487248118
Name:NEEDHAM, DOMINGA (PMHNP)
Entity type:Individual
Prefix:
First Name:DOMINGA
Middle Name:
Last Name:NEEDHAM
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 MARTIN LUTHER KING JR WAY FL 1
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1108
Mailing Address - Country:US
Mailing Address - Phone:888-588-8995
Mailing Address - Fax:510-756-0812
Practice Address - Street 1:2105 MARTIN LUTHER KING JR WAY FL 1
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1108
Practice Address - Country:US
Practice Address - Phone:885-888-8995
Practice Address - Fax:510-756-0812
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030432163WP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult