Provider Demographics
NPI:1043518046
Name:MEDINA-DOMINGUEZ, ROSE MARY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:MARY
Last Name:MEDINA-DOMINGUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:CHAMISAL
Mailing Address - State:NM
Mailing Address - Zip Code:87521-0036
Mailing Address - Country:US
Mailing Address - Phone:505-659-8769
Mailing Address - Fax:
Practice Address - Street 1:105 BERTHA RD STE B
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-7148
Practice Address - Country:US
Practice Address - Phone:575-758-4297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-087491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical