Provider Demographics
NPI:1639417264
Name:DOMINGUEZ, CARMEN JUDITH ROSARIO
Entity Type:Individual
Prefix:MISS
First Name:CARMEN JUDITH
Middle Name:ROSARIO
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 1:7509 PERLA DEL MAR AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89179-2500
Mailing Address - Country:US
Mailing Address - Phone:702-327-1907
Mailing Address - Fax:
Practice Address - Street 1:7509 PERLA DEL MAR AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89179-2500
Practice Address - Country:US
Practice Address - Phone:702-327-1907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling