Provider Demographics
NPI:1376094581
Name:DOMINGUEZ, MANUEL CRUZ JR
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:CRUZ
Last Name:DOMINGUEZ
Suffix:JR
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 1:4545 GEORGETOWN PL
Mailing Address - Street 2:SUITE A3
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6215
Mailing Address - Country:US
Mailing Address - Phone:209-955-1139
Mailing Address - Fax:
Practice Address - Street 1:4545 GEORGETOWN PL
Practice Address - Street 2:SUITE A3
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6215
Practice Address - Country:US
Practice Address - Phone:209-955-1139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health