Healthcare Provider Details

I. General information

NPI: 1043937790
Provider Name (Legal Business Name): ON THE MARGINS FAMILY THERAPY & PSYCHOLOGICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 KENTUCKY ST STE E
PETALUMA CA
94952-2877
US

IV. Provider business mailing address

245 KENTUCKY ST STE E
PETALUMA CA
94952-2877
US

V. Phone/Fax

Practice location:
  • Phone: 415-212-9064
  • Fax:
Mailing address:
  • Phone: 415-212-9064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIELA DOMINGUEZ
Title or Position: FOUNDER AND CHIEF EXECUTIVE OFFICER
Credential: PSYD
Phone: 415-209-5592