Provider Demographics
NPI:1528544640
Name:DOMINGUEZ, JOAN M
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:M
Other - Last Name:DE ST. AUBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5877 LIVERNOIS RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-3100
Mailing Address - Country:US
Mailing Address - Phone:313-550-0847
Mailing Address - Fax:
Practice Address - Street 1:5877 LIVERNOIS RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-3100
Practice Address - Country:US
Practice Address - Phone:313-550-0847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician