Healthcare Provider Details

I. General information

NPI: 1194595561
Provider Name (Legal Business Name): ALICIA DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 01/05/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 M ST
GERING NE
69341-2835
US

IV. Provider business mailing address

1513 11TH AVE
SCOTTSBLUFF NE
69361-2611
US

V. Phone/Fax

Practice location:
  • Phone: 308-633-3703
  • Fax:
Mailing address:
  • Phone: 308-765-8971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13742
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: