Provider Demographics
NPI:1598424855
Name:DOMINGUEZ, MARIJOSE
Entity Type:Individual
Prefix:
First Name:MARIJOSE
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53413
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619-3413
Mailing Address - Country:US
Mailing Address - Phone:951-228-2832
Mailing Address - Fax:714-333-4535
Practice Address - Street 1:6529 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3122
Practice Address - Country:US
Practice Address - Phone:951-228-2832
Practice Address - Fax:714-333-4535
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician