Provider Demographics
NPI:1942704887
Name:DOMINGUEZ, DIANA (LSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 MAGAZINE ST APT 201
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-3428
Mailing Address - Country:US
Mailing Address - Phone:732-632-7430
Mailing Address - Fax:
Practice Address - Street 1:228 LAFAYETTE ST FL 2
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1815
Practice Address - Country:US
Practice Address - Phone:973-789-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL062128001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical