Provider Demographics
NPI:1407374614
Name:DOMINGUEZ, ANGELICA CRISTINA
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:CRISTINA
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 1:4560 HALLMARK PKWY
Mailing Address - Street 2:P.O 9364
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-1886
Mailing Address - Country:US
Mailing Address - Phone:909-266-2700
Mailing Address - Fax:
Practice Address - Street 1:402 W BROADWAY STE 400
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3554
Practice Address - Country:US
Practice Address - Phone:866-478-3978
Practice Address - Fax:866-473-0365
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2025-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130942106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist