Provider Demographics
NPI:1669860912
Name:DOMINGUEZ, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MHC-LP
Mailing Address - Street 1:370 E 160TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-4404
Mailing Address - Country:US
Mailing Address - Phone:718-309-3090
Mailing Address - Fax:
Practice Address - Street 1:3600 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:917-612-9054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP90854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health