Provider Demographics
NPI:1447794839
Name:DOMINGUEZ, HENRIETTA CASILLAS (MA, LPC)
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:CASILLAS
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13300 OLD BLANCO RD STE 145
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-7738
Mailing Address - Country:US
Mailing Address - Phone:210-702-3066
Mailing Address - Fax:
Practice Address - Street 1:13300 OLD BLANCO RD STE 145
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7738
Practice Address - Country:US
Practice Address - Phone:210-702-3066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67659101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional