Provider Demographics
NPI:1104343409
Name:DOMIQUEL, MARICEL TABARES (MA)
Entity type:Individual
Prefix:
First Name:MARICEL
Middle Name:TABARES
Last Name:DOMIQUEL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:MARICEL
Other - Middle Name:DOMIQUEL
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:10808 FOOTHILL BLV
Mailing Address - Street 2:198
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:626-513-3847
Mailing Address - Fax:
Practice Address - Street 1:10808 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3889
Practice Address - Country:US
Practice Address - Phone:626-513-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst