Provider Demographics
NPI:1689155376
Name:DOMINGUEZ, MARIA LORENA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LORENA
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 1:3328 COUNTY ROAD 273
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:TX
Mailing Address - Zip Code:75946-7407
Mailing Address - Country:US
Mailing Address - Phone:936-645-0357
Mailing Address - Fax:
Practice Address - Street 1:4616 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1608
Practice Address - Country:US
Practice Address - Phone:936-569-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210754224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant