Provider Demographics
NPI:1730663873
Name:DOMENGEAUX, LISA M (MED)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:DOMENGEAUX
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 RUSHWING PL
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-4319
Mailing Address - Country:US
Mailing Address - Phone:281-719-5539
Mailing Address - Fax:281-715-4742
Practice Address - Street 1:25511 BUDDE RD STE 1002
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-2089
Practice Address - Country:US
Practice Address - Phone:281-719-5539
Practice Address - Fax:281-715-4742
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79369101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor