Provider Demographics
NPI:1992179659
Name:MOORE-DOMINGUEZ, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:MOORE-DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1901 S 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-6533
Mailing Address - Country:US
Mailing Address - Phone:956-289-7025
Mailing Address - Fax:956-289-7257
Practice Address - Street 1:1901 S 24TH AVE
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-6533
Practice Address - Country:US
Practice Address - Phone:956-289-7025
Practice Address - Fax:956-289-7257
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64939101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R945OtherMEDICARE
TX138708611Medicaid
TX138708613Medicaid