Healthcare Provider Details

I. General information

NPI: 1528690773
Provider Name (Legal Business Name): MARC ADRIAN DOMINGUEZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 N ORCHARD ST STE 110
BOISE ID
83706-2266
US

IV. Provider business mailing address

1299 N ORCHARD ST STE 110
BOISE ID
83706-2266
US

V. Phone/Fax

Practice location:
  • Phone: 208-658-3425
  • Fax:
Mailing address:
  • Phone: 208-658-3425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-42533
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: