Healthcare Provider Details

I. General information

NPI: 1710674981
Provider Name (Legal Business Name): NATASHA DOMINGUEZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 M. EVANS ST. #423
LITTLE RIVER ACADEMY TX
76554-9998
US

IV. Provider business mailing address

106 M. EVANS ST. #423
LITTLE RIVER ACADEMY TX
76554-9998
US

V. Phone/Fax

Practice location:
  • Phone: 832-619-9270
  • Fax:
Mailing address:
  • Phone: 832-619-9270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number91414
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401224289
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT-896
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101007411
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number205395
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: