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NPI Code Detail

MEDICARE: ON THE MARGINS FAMILY THERAPY & PSYCHOLOGICAL SERVICES, INC.

MEDICARE: ON THE MARGINS FAMILY THERAPY & PSYCHOLOGICAL SERVICES, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker
2106H00000XMarriage & Family Therapist
3171400000XHealth & Wellness Coach
4103T00000XPsychologist

General Provider Information

NPI Number : 1043937790
Entity Type Code : Organization
Provider Name (Legal Business Name) : ON THE MARGINS FAMILY THERAPY & PSYCHOLOGICAL SERVICES, INC.
Provider Business Mailing Address
First Line : 245 KENTUCKY ST STE E
Second Line :
City : PETALUMA
State : CA
Zip : 94952-2877
Country : US
Telephone Number : 415-212-9064
Fax Number :
Provider Business Practice Location Address
First Line : 245 KENTUCKY ST STE E
Second Line :
City : PETALUMA
State : CA
Zip : 94952-2877
Country : US
Telephone Number : 415-212-9064
Fax Number :
Authorized Official
Title or Position : FOUNDER AND CHIEF EXECUTIVE OFFICER
Name : DR. DANIELA DOMINGUEZ
Credential : PSYD
Telephone Number : 415-209-5592
Provider Enumeration Date : 10/24/2022
Last Update Date : 10/03/2024

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