Provider Demographics
NPI:1669199089
Name:DOMINGUEZ, LISANDRA M I (PSYD)
Entity type:Individual
Prefix:MISS
First Name:LISANDRA
Middle Name:M
Last Name:DOMINGUEZ
Suffix:I
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9023711
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00902-3711
Mailing Address - Country:US
Mailing Address - Phone:787-993-3885
Mailing Address - Fax:
Practice Address - Street 1:1 CALLE RAMON GOMEZ S
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3939
Practice Address - Country:US
Practice Address - Phone:787-547-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7791103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical