Provider Demographics
NPI:1013689447
Name:DOMINGO, ANA CECILIA
Entity Type:Individual
Prefix:MISS
First Name:ANA
Middle Name:CECILIA
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3539 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-7032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3539 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-7032
Practice Address - Country:US
Practice Address - Phone:619-818-3788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12295101Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program