Healthcare Provider Details

I. General information

NPI: 1649471293
Provider Name (Legal Business Name): JOEL AARON DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9828 CENTRAL AVE
MONTCLAIR CA
91763-2817
US

IV. Provider business mailing address

815 COLORADO BLVD STE 300
LOS ANGELES CA
90041-1744
US

V. Phone/Fax

Practice location:
  • Phone: 909-447-7520
  • Fax:
Mailing address:
  • Phone: 323-543-2800
  • Fax: 323-978-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF67191
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: