Provider Demographics
NPI:1558909267
Name:DOMINGUEZ, ERCILIA (MFT)
Entity Type:Individual
Prefix:
First Name:ERCILIA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14545 SHERMAN WAY CIR
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405
Mailing Address - Country:US
Mailing Address - Phone:818-901-4930
Mailing Address - Fax:
Practice Address - Street 1:14545 SHERMAN WAY CIR
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405
Practice Address - Country:US
Practice Address - Phone:818-901-4830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA206722101YA0400X
CAAMFT112092225400000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner