Provider Demographics
NPI:1548969462
Name:MASSIMO, DOMINIC MICHAEL III
Entity type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:MICHAEL
Last Name:MASSIMO
Suffix:III
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 1:3785 E SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-6259
Mailing Address - Country:US
Mailing Address - Phone:725-203-3073
Mailing Address - Fax:
Practice Address - Street 1:3785 E SUNSET RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-6259
Practice Address - Country:US
Practice Address - Phone:725-203-3073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No175T00000XOther Service ProvidersPeer Specialist