Provider Demographics
NPI:1205045473
Name:DOMIN, RONALD
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:
Last Name:DOMIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1466 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2021
Mailing Address - Country:US
Mailing Address - Phone:415-457-3755
Mailing Address - Fax:
Practice Address - Street 1:1466 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2021
Practice Address - Country:US
Practice Address - Phone:415-457-4755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor