Healthcare Provider Details

I. General information

NPI: 1063109924
Provider Name (Legal Business Name): REISA ISEL DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 S MAIN ST STE 201
CORONA CA
92882-5303
US

IV. Provider business mailing address

2275 S MAIN ST STE 201
CORONA CA
92882-5303
US

V. Phone/Fax

Practice location:
  • Phone: 951-279-3222
  • Fax: 951-279-5222
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: