MEDICARE: SEQUOIA FAMILY THERAPY, PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1053147058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEQUOIA FAMILY THERAPY, PLLC

Provider Business Mailing Address
First Line	:	539 W COMMERCE ST # 5466
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-1953
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1071 LAKE CAROLYN PARKWAY
Second Line	:	APT 4064
City	:	IRVING
State	:	TX
Zip	:	75039
Country	:	US
Telephone Number	:	469-364-9730
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	PRISCILLA GUADALUPE DOMINGUEZ
Credential	:	MFT-ASSOCIATE
Telephone Number	:	469-364-9730

Provider Enumeration Date	:	09/09/2024
Last Update Date	:	09/09/2024

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