Healthcare Provider Details

I. General information

NPI: 1295662229
Provider Name (Legal Business Name): SANDRA DAMARIS DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 VAN CORTLANDT PARK S APT DD42
BRONX NY
10463-0610
US

IV. Provider business mailing address

74 VAN CORTLANDT PARK S APT DD42
BRONX NY
10463-0610
US

V. Phone/Fax

Practice location:
  • Phone: 646-270-1705
  • Fax:
Mailing address:
  • Phone: 646-270-1705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: