MEDICARE: MRS. ROSE MARY MEDINA-DOMINGUEZ LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C-08749	NM

General Provider Information

NPI Number	:	1043518046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ROSE MARY MEDINA-DOMINGUEZ LCSW

Provider Business Mailing Address
First Line	:	PO BOX 36
Second Line	:
City	:	CHAMISAL
State	:	NM
Zip	:	87521-0036
Country	:	US
Telephone Number	:	505-659-8769
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 BERTHA RD STE B
Second Line	:
City	:	TAOS
State	:	NM
Zip	:	87571-7148
Country	:	US
Telephone Number	:	575-758-4297
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2011
Last Update Date	:	02/05/2024

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