Healthcare Provider Details

I. General information

NPI: 1124276191
Provider Name (Legal Business Name): MARK ANTHONY DOMINGUEZ MA PSYCH LMFT135452
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 06/09/2024
Certification Date: 06/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 18TH ST STE 300
BAKERSFIELD CA
93301-4433
US

IV. Provider business mailing address

6505 BRIDGEPORT LN
BAKERSFIELD CA
93309-3404
US

V. Phone/Fax

Practice location:
  • Phone: 661-865-2352
  • Fax:
Mailing address:
  • Phone: 661-865-2352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT135452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: