Provider Demographics
NPI:1144784737
Name:MARCILLA, DOMINIC (CO60930415)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:MARCILLA
Suffix:
Gender:M
Credentials:CO60930415
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 W 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2506
Mailing Address - Country:US
Mailing Address - Phone:509-315-9791
Mailing Address - Fax:
Practice Address - Street 1:312 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2506
Practice Address - Country:US
Practice Address - Phone:509-315-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60930415101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)