Provider Demographics
NPI:1942632336
Name:DOMINGUEZ, OLIVIA NOELLE (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:NOELLE
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 1:723 BELVIDERE ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-2251
Mailing Address - Country:US
Mailing Address - Phone:256-856-0102
Mailing Address - Fax:
Practice Address - Street 1:1101 E SCHUSTER AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4659
Practice Address - Country:US
Practice Address - Phone:915-544-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112898235Z00000X
WALL60385093235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist