Provider Demographics
NPI:1679018808
Name:DOMINGUEZ, MARITZA
Entity Type:Individual
Prefix:
First Name:MARITZA
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 1:1520 TETA DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-4048
Mailing Address - Country:US
Mailing Address - Phone:951-454-4346
Mailing Address - Fax:
Practice Address - Street 1:1425 W FOOTHILL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3689
Practice Address - Country:US
Practice Address - Phone:722-787-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-26
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health