Healthcare Provider Details

I. General information

NPI: 1316819121
Provider Name (Legal Business Name): CARLOS ANTONIO DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2025
Last Update Date: 09/22/2025
Certification Date: 09/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 KENT HILL RD
EAST CALAIS VT
05650-8048
US

IV. Provider business mailing address

760 KENT HILL RD
EAST CALAIS VT
05650-8048
US

V. Phone/Fax

Practice location:
  • Phone: 802-793-9850
  • Fax:
Mailing address:
  • Phone: 802-793-9850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number097.0136523
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: