Basic Information
| Provider Information | |||||||||
| NPI: | 1073662367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIANTONIO | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | J | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 PINE STREET | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087659167 | ||||||||
| FaxNumber: | 5087642462 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 PINE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015501823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087649167 | ||||||||
| FaxNumber: | 5087642462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 11/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 5151 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1200704 | 05 | MA | MEDICAID |