Provider Demographics
NPI:1376159558
Name:DOMINGUEZ, COLETTE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:COLETTE
Other - Middle Name:
Other - Last Name:FORTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:1461 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8013
Mailing Address - Country:US
Mailing Address - Phone:312-639-3072
Mailing Address - Fax:
Practice Address - Street 1:1461 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8013
Practice Address - Country:US
Practice Address - Phone:312-639-3072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist