Provider Demographics
NPI:1598340366
Name:DOMINO, MARLA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARLA
Middle Name:
Last Name:DOMINO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3938 E GRANT RD # 152
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2559
Mailing Address - Country:US
Mailing Address - Phone:520-800-3825
Mailing Address - Fax:
Practice Address - Street 1:3045 N 1ST AVE STE A
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2560
Practice Address - Country:US
Practice Address - Phone:520-800-3825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4878103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical