Healthcare Provider Details

I. General information

NPI: 1942632336
Provider Name (Legal Business Name): OLIVIA NOELLE DOMINGUEZ M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E SCHUSTER AVE
EL PASO TX
79902-4659
US

IV. Provider business mailing address

723 BELVIDERE ST
EL PASO TX
79912-2251
US

V. Phone/Fax

Practice location:
  • Phone: 915-544-8484
  • Fax:
Mailing address:
  • Phone: 256-856-0102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number112898
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL60385093
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: