| Doctor Name: | MR. DOMINIC IDOKO |
| NPI Number: | 1023131083 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MA |
| License Number: | |
| Business Practice Address: | 100 South St Southbridge, MA - 015504051 |
| Business Phone Number: | 5087659771 |
| Business Fax Number: | 5087653147 |
| Mailing Address: | 100 South St, SOUTHBRIDGE |
| State: | MA |
| Postal Code: | 015504051 |
| Phone Number: | 5087659771 |
| Fax Number: | 5087653147 |
| NPI Enumeration Date: | 04/06/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |