Provider Demographics
NPI:1013336510
Name:DOMINGO, SAMANTHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3521 NW SAMARITAN DR STE 201
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4744
Practice Address - Country:US
Practice Address - Phone:541-768-5140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-11
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 103TB0200X
OR2791103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral