Healthcare Provider Details

I. General information

NPI: 1528825189
Provider Name (Legal Business Name): TAYLOR ERNEST LYLE DOMEK LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 N MAIN ST STE 1
LAS CRUCES NM
88001-1281
US

IV. Provider business mailing address

414 N MAIN ST STE 1
LAS CRUCES NM
88001-1281
US

V. Phone/Fax

Practice location:
  • Phone: 575-600-6575
  • Fax:
Mailing address:
  • Phone: 575-600-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2025-0695
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: