Healthcare Provider Details

I. General information

NPI: 1356507586
Provider Name (Legal Business Name): MARY ANN DOM LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6502 BANDERA RD STE 202
LEON VALLEY TX
78238-1454
US

IV. Provider business mailing address

2186 JACKSON KELLER RD STE 2134
SAN ANTONIO TX
78213-2723
US

V. Phone/Fax

Practice location:
  • Phone: 210-488-0384
  • Fax: 210-941-0682
Mailing address:
  • Phone: 210-488-0384
  • Fax: 210-941-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12359
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12359
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number12359
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: