Provider Demographics
NPI:1366623811
Name:DOMINGUEZ, ROSALVA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ROSALVA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ROSIE
Other - Middle Name:
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:2214 REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-6346
Mailing Address - Country:US
Mailing Address - Phone:562-205-6156
Mailing Address - Fax:
Practice Address - Street 1:11731 TELEGRAPH RD STE K
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-6815
Practice Address - Country:US
Practice Address - Phone:562-907-7429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 22403101YM0800X
CA912221041C0700X
CALCSW912221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XOtherASSOCIATE CLINICAL SOCIAL WORKER