Provider Demographics
NPI:1699382952
Name:DOMINGUEZ, SARAH OLIVIA
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:OLIVIA
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 1:1221 MOTTMAN RD SW APT A202
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-8358
Mailing Address - Country:US
Mailing Address - Phone:913-704-5606
Mailing Address - Fax:
Practice Address - Street 1:3443 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-3091
Practice Address - Country:US
Practice Address - Phone:360-456-2237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician