Provider Demographics
NPI:1023671849
Name:DOMINGUEZ, MARIA MERCEDES (PHD, LMFT)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:MERCEDES
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 ILLINOIS AVE UNIT 752
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-3232
Mailing Address - Country:US
Mailing Address - Phone:808-600-4458
Mailing Address - Fax:
Practice Address - Street 1:124 ELLIS ST
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-1148
Practice Address - Country:US
Practice Address - Phone:808-600-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI562106H00000X
MI4101006781106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist