Healthcare Provider Details

I. General information

NPI: 1073130316
Provider Name (Legal Business Name): EDGAR DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 ATLANTIC AVE STE 210
LONG BEACH CA
90807-4569
US

IV. Provider business mailing address

3530 ATLANTIC AVE STE 210
LONG BEACH CA
90807-4569
US

V. Phone/Fax

Practice location:
  • Phone: 562-424-1886
  • Fax:
Mailing address:
  • Phone: 562-424-1886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number161160
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: