Provider Demographics
NPI:1518521830
Name:FRAGOSO, DOMINIQUE ANNE MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:ANNE MARIE
Last Name:FRAGOSO
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 1:950 REDBUD RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6644
Mailing Address - Country:US
Mailing Address - Phone:619-977-0399
Mailing Address - Fax:
Practice Address - Street 1:215 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3405
Practice Address - Country:US
Practice Address - Phone:619-401-6236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126011041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool