Provider Demographics
NPI:1902817174
Name:DOMINGUEZ, HEATHER S (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:S
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11227 E SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-7052
Mailing Address - Country:US
Mailing Address - Phone:602-510-2140
Mailing Address - Fax:
Practice Address - Street 1:10049 E DYNAMITE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-3694
Practice Address - Country:US
Practice Address - Phone:602-510-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1861235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ649808Medicaid