Provider Demographics
NPI:1962037341
Name:DOMINGUEZ, REBECCA ROSE (LMSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ROSE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-1630
Mailing Address - Country:US
Mailing Address - Phone:516-941-8204
Mailing Address - Fax:
Practice Address - Street 1:91 GUY LOMBARDO AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3731
Practice Address - Country:US
Practice Address - Phone:516-868-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108756-011041C0700X, 1041S0200X
1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool