Provider Demographics
NPI:1205943537
Name:DOMINGUEZ, MARTHA (LCSW, LMFT)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 GATEWAY BLVD W STE 570
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3395
Mailing Address - Country:US
Mailing Address - Phone:915-772-1829
Mailing Address - Fax:915-772-5133
Practice Address - Street 1:5959 GATEWAY BLVD W
Practice Address - Street 2:SUITE 501
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3331
Practice Address - Country:US
Practice Address - Phone:915-772-1829
Practice Address - Fax:915-772-5133
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3959106H00000X
TX12491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S18WOtherBXBS
TX1164899-03Medicaid
TX00S18WOtherBXBS