MEDICARE: TARYN MICHELLE DOMINGUEZ LISW-CP

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
1	1041C0700X	Clinical Social Worker	9289	TN

General Provider Information

NPI Number	:	1669179008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARYN MICHELLE DOMINGUEZ LISW-CP

Provider Business Mailing Address
First Line	:	234 NELLIEFIELD CREEK DR
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29492-8313
Country	:	US
Telephone Number	:	843-437-0258
Fax Number	:

Provider Business Practice Location Address
First Line	:	234 NELLIEFIELD CREEK DR
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29492-8313
Country	:	US
Telephone Number	:	843-437-0258
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2023
Last Update Date	:	02/15/2023

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