Provider Demographics
NPI:1265625156
Name:DOMINGUEZ, RITA
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:DOMINGUEZ
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:P.O. DRAWER 70
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021
Mailing Address - Country:US
Mailing Address - Phone:575-882-6101
Mailing Address - Fax:575-882-6926
Practice Address - Street 1:1301 WEST WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021
Practice Address - Country:US
Practice Address - Phone:505-882-6200
Practice Address - Fax:505-882-6280
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-2391101YS0200X
NMB23911041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool