Provider Demographics
NPI:1629247861
Name:DOMINGUEZ, SHANTAL ARELIS (BA)
Entity Type:Individual
Prefix:MISS
First Name:SHANTAL
Middle Name:ARELIS
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 PINEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-3640
Mailing Address - Country:US
Mailing Address - Phone:909-544-7276
Mailing Address - Fax:
Practice Address - Street 1:1359 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1016
Practice Address - Country:US
Practice Address - Phone:626-430-2900
Practice Address - Fax:626-331-0035
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN796OtherLA COUNTY DMH