Provider Demographics
NPI:1831579267
Name:DOMINQUEZ-WIGGINS, DEBBIE ANN (BSC)
Entity type:Individual
Prefix:
First Name:DEBBIE
Middle Name:ANN
Last Name:DOMINQUEZ-WIGGINS
Suffix:
Gender:F
Credentials:BSC
Other - Prefix:
Other - First Name:DEBBIE
Other - Middle Name:ANN
Other - Last Name:WIGGINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BSC
Mailing Address - Street 1:1296 LOHRMAN LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-1650
Mailing Address - Country:US
Mailing Address - Phone:707-290-1899
Mailing Address - Fax:707-776-4794
Practice Address - Street 1:1296 LOHRMAN LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-1650
Practice Address - Country:US
Practice Address - Phone:707-290-1899
Practice Address - Fax:707-776-4794
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-YDOLQH175T00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor