Provider Demographics
NPI:1770785560
Name:DOMINGUEZ, HECTOR M (CACI)
Entity type:Individual
Prefix:
First Name:HECTOR
Middle Name:M
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:CACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 RIVERVIEW DR
Mailing Address - Street 2:STE 180 BLDG A
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022
Mailing Address - Country:US
Mailing Address - Phone:269-926-0121
Mailing Address - Fax:269-926-0584
Practice Address - Street 1:777 RIVERVIEW DR
Practice Address - Street 2:STE 180 BLDG A
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022
Practice Address - Country:US
Practice Address - Phone:269-926-0121
Practice Address - Fax:269-926-0584
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor