Healthcare Provider Details

I. General information

NPI: 1124517156
Provider Name (Legal Business Name): CAITLYN ELIZABETH DOMINGUEZ BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7415 HENRIETTA DR
SACRAMENTO CA
95822-5142
US

IV. Provider business mailing address

3440 VIKING DR
SACRAMENTO CA
95827-2844
US

V. Phone/Fax

Practice location:
  • Phone: 916-896-7480
  • Fax:
Mailing address:
  • Phone: 916-364-8395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: