Healthcare Provider Details

I. General information

NPI: 1083403455
Provider Name (Legal Business Name): MARISSA ROSE DOMINGUEZ LMFT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E 29TH ST STE 237
LOVELAND CO
80538-2765
US

IV. Provider business mailing address

4359 BIRCHWOOD DR
LOVELAND CO
80538-5618
US

V. Phone/Fax

Practice location:
  • Phone: 970-203-4051
  • Fax:
Mailing address:
  • Phone: 970-203-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARISSA DOMINGUEZ
Title or Position: OWNER
Credential: LMFT
Phone: 970-203-4051