Healthcare Provider Details

I. General information

NPI: 1699326850
Provider Name (Legal Business Name): KIANA DOMENIK-ALEXIS DINIZ LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 COFFEE RD
MODESTO CA
95355-4233
US

IV. Provider business mailing address

800 COFFEE RD
MODESTO CA
95355-4233
US

V. Phone/Fax

Practice location:
  • Phone: 209-554-6808
  • Fax:
Mailing address:
  • Phone: 209-554-6808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: