Healthcare Provider Details

I. General information

NPI: 1720840697
Provider Name (Legal Business Name): LUISA DOMINGUEZ LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 MAIN ST # 1
HACKENSACK NJ
07601-4907
US

IV. Provider business mailing address

165 PASSAIC AVE STE 200
FAIRFIELD NJ
07004-3521
US

V. Phone/Fax

Practice location:
  • Phone: 201-678-1802
  • Fax:
Mailing address:
  • Phone: 800-413-8020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number44SL06478000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: