Provider Demographics
NPI:1023257656
Name:DOMINGUEZ, MARCELLE (LCSW)
Entity type:Individual
Prefix:
First Name:MARCELLE
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 FERGUSON RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-9637
Mailing Address - Country:US
Mailing Address - Phone:707-339-0398
Mailing Address - Fax:707-829-2729
Practice Address - Street 1:576 B ST
Practice Address - Street 2:SUITE 1-B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5273
Practice Address - Country:US
Practice Address - Phone:707-339-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical