Provider Demographics
NPI:1427543297
Name:DOMINGUEZ, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
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 1:10877 CONDUCTOR BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SUTTER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95685-9688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10877 CONDUCTOR BLVD
Practice Address - Street 2:
Practice Address - City:SUTTER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95685-9687
Practice Address - Country:US
Practice Address - Phone:209-223-6412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4666101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health