Healthcare Provider Details

I. General information

NPI: 1124834171
Provider Name (Legal Business Name): ALVA M DOMINGUEZ SANCHEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16041 KAMANA RD STE A
APPLE VALLEY CA
92307-1331
US

IV. Provider business mailing address

PO BOX 401224
HESPERIA CA
92340-1224
US

V. Phone/Fax

Practice location:
  • Phone: 760-503-1208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number92687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: