Provider Demographics
NPI:1114446044
Name:LABEAU, DOMENIQUE (LMFT)
Entity Type:Individual
Prefix:
First Name:DOMENIQUE
Middle Name:
Last Name:LABEAU
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:DOMENIQUE
Other - Middle Name:
Other - Last Name:ANCONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFTI
Mailing Address - Street 1:33562 YUCAIPA BLVD.
Mailing Address - Street 2:STE. 4 PMB 503
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399
Mailing Address - Country:US
Mailing Address - Phone:909-472-1591
Mailing Address - Fax:
Practice Address - Street 1:18 E STATE ST STE 206
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4773
Practice Address - Country:US
Practice Address - Phone:909-747-9038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119874106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist