=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982323226
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINI BEATTY MA, AMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2022
-----------------------------------------------------
Last Update Date | 09/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 W LA VETA AVE
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92868-4203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-583-6810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2664 LAS COLIMAS
-----------------------------------------------------
City | LA VERNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91750-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-485-6257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 131103
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------