Provider Demographics
NPI:1417209743
Name:DOMINGOS, ANALIESE MEG (LCSW)
Entity Type:Individual
Prefix:
First Name:ANALIESE
Middle Name:MEG
Last Name:DOMINGOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 E SHAW AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-7717
Mailing Address - Country:US
Mailing Address - Phone:559-285-2921
Mailing Address - Fax:559-468-6041
Practice Address - Street 1:770 E SHAW AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7717
Practice Address - Country:US
Practice Address - Phone:559-285-2921
Practice Address - Fax:559-468-6041
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA730501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical