Provider Demographics
NPI:1437700200
Name:DOMINGUEZ, NICOLE LEANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LEANN
Last Name:DOMINGUEZ
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 1:2425 SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-3908
Mailing Address - Country:US
Mailing Address - Phone:408-824-3922
Mailing Address - Fax:
Practice Address - Street 1:2425 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-3908
Practice Address - Country:US
Practice Address - Phone:408-824-3922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA912211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical