Provider Demographics
NPI:1023362142
Name:DOMINGUEZ, CANDICE LEANN
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:LEANN
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40936 E COUNTY ROAD 1230
Mailing Address - Street 2:
Mailing Address - City:KEOTA
Mailing Address - State:OK
Mailing Address - Zip Code:74941-6439
Mailing Address - Country:US
Mailing Address - Phone:918-471-8936
Mailing Address - Fax:
Practice Address - Street 1:40936 E COUNTY ROAD 1230
Practice Address - Street 2:
Practice Address - City:KEOTA
Practice Address - State:OK
Practice Address - Zip Code:74941-6439
Practice Address - Country:US
Practice Address - Phone:918-471-8936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-14-12101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor