Healthcare Provider Details

I. General information

NPI: 1568352441
Provider Name (Legal Business Name): SELENA DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1084 S MAIN ST STE A
BOWLING GREEN OH
43402-4740
US

IV. Provider business mailing address

1084 S MAIN ST STE A
BOWLING GREEN OH
43402-4740
US

V. Phone/Fax

Practice location:
  • Phone: 419-352-4624
  • Fax: 419-936-7606
Mailing address:
  • Phone: 419-352-4624
  • Fax: 419-936-7606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2605029-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: