Healthcare Provider Details

I. General information

NPI: 1811823560
Provider Name (Legal Business Name): ATYPICAL THERAPIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13178 E MINETA RIDGE DR
VAIL AZ
85641-2522
US

IV. Provider business mailing address

13178 E MINETA RIDGE DR
VAIL AZ
85641-2522
US

V. Phone/Fax

Practice location:
  • Phone: 520-329-1431
  • Fax:
Mailing address:
  • Phone: 520-329-1431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KERRI LYNN ELMINA DOMINGUEZ
Title or Position: OWNER
Credential: LPC
Phone: 520-329-1431