Healthcare Provider Details

I. General information

NPI: 1174764732
Provider Name (Legal Business Name): CECILIA M DOMINGUEZ PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 NE 139TH ST STE 265
VANCOUVER WA
98686-2311
US

IV. Provider business mailing address

2209 E 2ND ST APT 6
LOS ANGELES CA
90033-3960
US

V. Phone/Fax

Practice location:
  • Phone: 360-487-2700
  • Fax: 360-487-2701
Mailing address:
  • Phone: 415-515-7364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2673
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60666459
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: