Healthcare Provider Details

I. General information

NPI: 1275409724
Provider Name (Legal Business Name): MARISSA MARIE FRUTOS- DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 10/24/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 GRANT RD STE 110
MOUNTAIN VIEW CA
94040-3270
US

IV. Provider business mailing address

1922 THE ALAMEDA SUITE 316
SAN JOSE CA
95126
US

V. Phone/Fax

Practice location:
  • Phone: 650-484-1213
  • Fax: 408-642-6052
Mailing address:
  • Phone: 408-261-7777
  • Fax: 408-642-6052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: