Provider Demographics
NPI:1063228013
Name:DOMENIQUE LABEAU, LICENSED MARRIAGE AND FAMILY THERAPIST, INC.
Entity type:Organization
Organization Name:DOMENIQUE LABEAU, LICENSED MARRIAGE AND FAMILY THERAPIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMENIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:LABEAU
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:909-747-9038
Mailing Address - Street 1:33562 YUCAIPA BLVD.
Mailing Address - Street 2:STE. 4, PMB 503
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1457 EDELWEISS DR UNIT E
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-3377
Practice Address - Country:US
Practice Address - Phone:909-747-9038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114446044OtherINDIVIDUAL