Healthcare Provider Details

I. General information

NPI: 1124644711
Provider Name (Legal Business Name): SERENA OSULLIVAN DINGLER DOMINGUEZ LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 ALBERTO WAY STE 170
LOS GATOS CA
95032-5481
US

IV. Provider business mailing address

PO BOX 378
SAN MARTIN CA
95046-0378
US

V. Phone/Fax

Practice location:
  • Phone: 408-359-7535
  • Fax:
Mailing address:
  • Phone: 408-812-0872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number162484
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: