Provider Demographics
NPI:1083198741
Name:KINTSUGI THERAPY SERVICES
Entity Type:Organization
Organization Name:KINTSUGI THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:MIGDALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:612-310-0424
Mailing Address - Street 1:1205 OXFORD WAY
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-6445
Mailing Address - Country:US
Mailing Address - Phone:612-310-0424
Mailing Address - Fax:
Practice Address - Street 1:1205 OXFORD WAY
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-6445
Practice Address - Country:US
Practice Address - Phone:612-279-8677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty