Provider Demographics
NPI:1104279256
Name:MONSIVAIS DOMINGUEZ, ROXANA N
Entity type:Individual
Prefix:
First Name:ROXANA
Middle Name:N
Last Name:MONSIVAIS 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 1:764 E TWAIN AVE APT 15G
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-4127
Mailing Address - Country:US
Mailing Address - Phone:702-334-7769
Mailing Address - Fax:
Practice Address - Street 1:2920 S JONES BLVD STE 225
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5622
Practice Address - Country:US
Practice Address - Phone:702-476-6395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1104279256101YM0800X
101YA0400X
NV1104279256101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1104279256Medicaid