Healthcare Provider Details

I. General information

NPI: 1528825189
Provider Name (Legal Business Name): TAYLOR EARNEST DOMEK CPSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 W AMADOR AVE STE A
LAS CRUCES NM
88005-2739
US

IV. Provider business mailing address

PO BOX 2243
LAS CRUCES NM
88004-2243
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-5482
  • Fax: 575-652-4243
Mailing address:
  • Phone: 575-527-5482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2025-0695
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1701
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: