Basic Information
| Provider Information | |||||||||
| NPI: | 1336468487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIDOMENICO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3995 MARCOLA RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974777948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417261465 | ||||||||
| FaxNumber: | 5417265085 | ||||||||
| Practice Location | |||||||||
| Address1: | 3995 MARCOLA RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974777948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417261465 | ||||||||
| FaxNumber: | 5417265085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.