Provider Demographics
NPI:1013698042
Name:DOMAN, MLISS M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MLISS
Middle Name:M
Last Name:DOMAN
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 1:12277 APPLE VALLEY RD # 133
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-1701
Mailing Address - Country:US
Mailing Address - Phone:760-900-1963
Mailing Address - Fax:
Practice Address - Street 1:16366 RIDGE VIEW DR
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1243
Practice Address - Country:US
Practice Address - Phone:760-900-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25598103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist