Healthcare Provider Details

I. General information

NPI: 1477709483
Provider Name (Legal Business Name): SUSAN DOMINGUEZ PSY24264
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2008
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 ADELINE ST
BERKELEY CA
94703-2407
US

IV. Provider business mailing address

6010 HIGHWAY 9 STE 7
FELTON CA
95018-9535
US

V. Phone/Fax

Practice location:
  • Phone: 510-601-0203
  • Fax: 510-601-4002
Mailing address:
  • Phone: 831-515-6817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPSY24264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: