Provider Demographics
NPI:1306216064
Name:MARTHA DOMINGUEZ LICENSED MENTAL HEALTH COUNSELOR BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:MARTHA DOMINGUEZ LICENSED MENTAL HEALTH COUNSELOR BEHAVIORAL HEALTH
Other - Org Name:BEHAVIORAL HEALTH INTEGRATIVE SERVICES PC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-309-3090
Mailing Address - Street 1:370 E 160TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-4404
Mailing Address - Country:US
Mailing Address - Phone:718-309-3090
Mailing Address - Fax:
Practice Address - Street 1:370 E 160TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-4404
Practice Address - Country:US
Practice Address - Phone:718-309-3090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty