Healthcare Provider Details

I. General information

NPI: 1265625156
Provider Name (Legal Business Name): RITA DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 WEST WASHINGTON STREET
ANTHONY NM
88021
US

IV. Provider business mailing address

P.O. DRAWER 70
ANTHONY NM
88021
US

V. Phone/Fax

Practice location:
  • Phone: 505-882-6200
  • Fax: 505-882-6280
Mailing address:
  • Phone: 575-882-6101
  • Fax: 575-882-6926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberB-2391
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberB2391
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: