Provider Demographics
NPI:1730366956
Name:IANNOTTI, DOMINICK J (LADC)
Entity type:Individual
Prefix:
First Name:DOMINICK
Middle Name:J
Last Name:IANNOTTI
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MARY ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:571 SABATTUS ST
Practice Address - Street 2:SUITE 6
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-4156
Practice Address - Country:US
Practice Address - Phone:207-784-4364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC1106101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)