Provider Demographics
NPI:1649537408
Name:LY, DOMINIE TRANG
Entity type:Individual
Prefix:
First Name:DOMINIE
Middle Name:TRANG
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRANG
Other - Middle Name:QUYNH
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:2124 W HARRIET LN
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-6040
Mailing Address - Country:US
Mailing Address - Phone:714-600-2719
Mailing Address - Fax:
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-583-6185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW242661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical