Provider Demographics
NPI:1417670985
Name:DOMINGUEZ, DRENA
Entity Type:Individual
Prefix:
First Name:DRENA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 E WALNUT ST STE 117
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-5129
Mailing Address - Country:US
Mailing Address - Phone:626-773-4364
Mailing Address - Fax:
Practice Address - Street 1:1245 E WALNUT ST STE 117
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-5129
Practice Address - Country:US
Practice Address - Phone:626-773-4364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15893-RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15893RACOtherSUD COUNSELOR