Provider Demographics
NPI:1083130942
Name:DOMINGUEZ, LILIANA
Entity Type:Individual
Prefix:MISS
First Name:LILIANA
Middle Name:
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 1:460 E CARSON PLAZA DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3270
Mailing Address - Country:US
Mailing Address - Phone:310-523-9500
Mailing Address - Fax:
Practice Address - Street 1:460 E CARSON PLAZA DR STE 102
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3270
Practice Address - Country:US
Practice Address - Phone:310-523-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW77668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health