Provider Demographics
NPI:1790027779
Name:DOMINGUEZ, MARIA VIRGINIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:VIRGINIA
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 1:540 REEF RD
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-2801
Mailing Address - Country:US
Mailing Address - Phone:915-637-3143
Mailing Address - Fax:
Practice Address - Street 1:2920 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5605
Practice Address - Country:US
Practice Address - Phone:772-340-5044
Practice Address - Fax:772-293-0347
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health