Healthcare Provider Details

I. General information

NPI: 1285055855
Provider Name (Legal Business Name): ISABELLE DOMINGUEZ LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2013
Last Update Date: 12/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N ALAMEDA BLVD
LAS CRUCES NM
88005-1725
US

IV. Provider business mailing address

PO BOX 374
MESILLA NM
88046-0374
US

V. Phone/Fax

Practice location:
  • Phone: 575-496-0883
  • Fax:
Mailing address:
  • Phone: 575-496-0883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0092151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: