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NPI Code Detail

MEDICARE: MRS. SUSAN DOMINGUEZ PSY24264

MEDICARE: MRS. SUSAN DOMINGUEZ PSY24264
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
1103TM1800XIntellectual & Developmental Disabilities PsychologistPSY24264CA

General Provider Information

NPI Number : 1477709483
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. SUSAN DOMINGUEZ PSY24264
Provider Business Mailing Address
First Line : 6010 HIGHWAY 9 STE 7
Second Line :
City : FELTON
State : CA
Zip : 95018-9535
Country : US
Telephone Number : 831-515-6817
Fax Number :
Provider Business Practice Location Address
First Line : 3200 ADELINE ST
Second Line :
City : BERKELEY
State : CA
Zip : 94703-2407
Country : US
Telephone Number : 510-601-0203
Fax Number : 510-601-4002
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/09/2008
Last Update Date : 02/04/2026

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