Provider Demographics
NPI:1932427457
Name:SOTELO, DOMINIQUE L (LMFT)
Entity Type:Individual
Prefix:MR
First Name:DOMINIQUE
Middle Name:L
Last Name:SOTELO
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 LIBERTY RD NE
Mailing Address - Street 2:SUITE 370
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3505
Mailing Address - Country:US
Mailing Address - Phone:503-910-4165
Mailing Address - Fax:971-925-4154
Practice Address - Street 1:155 LIBERTY ST NE STE 370
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3552
Practice Address - Country:US
Practice Address - Phone:503-910-4165
Practice Address - Fax:971-925-4154
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0669106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist