Provider Demographics
NPI:1710373394
Name:DOMINGUEZ, REBECCA ANN (ATC, LAT)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ANN
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 EL MUNDO RD
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-7006
Mailing Address - Country:US
Mailing Address - Phone:505-966-1314
Mailing Address - Fax:505-966-1351
Practice Address - Street 1:115 EL MUNDO RD
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-7006
Practice Address - Country:US
Practice Address - Phone:505-966-1314
Practice Address - Fax:505-966-1351
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer