Provider Demographics
NPI:1831765320
Name:DOMINGUEZ, MARK A (MA PSYA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MA PSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD PK
Mailing Address - State:NJ
Mailing Address - Zip Code:07660
Mailing Address - Country:US
Mailing Address - Phone:201-641-5648
Mailing Address - Fax:201-440-8580
Practice Address - Street 1:800 CATALPA AVE
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666
Practice Address - Country:US
Practice Address - Phone:201-641-5648
Practice Address - Fax:201-440-8580
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst