Provider Demographics
NPI:1649829417
Name:DABOIN DOMINGUEZ, IRENE (PHD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:DABOIN DOMINGUEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:
Other - Last Name:DABOIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1409 N HIGHLAND AVE NE STE J
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1409 N HIGHLAND AVE NE STE J
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-3300
Practice Address - Country:US
Practice Address - Phone:770-765-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004248103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical