Provider Demographics
NPI:1033777255
Name:DOMINGUEZ, SAN JUANITA (MS, SLP INTERN)
Entity Type:Individual
Prefix:
First Name:SAN JUANITA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MS, SLP INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 LOUISIANA AVE APT 6106
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-5825
Mailing Address - Country:US
Mailing Address - Phone:956-206-1750
Mailing Address - Fax:
Practice Address - Street 1:3333 BAYSHORE BLVD STE 340
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1960
Practice Address - Country:US
Practice Address - Phone:713-910-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115540235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist