Provider Demographics
NPI:1124276191
Name:DOMINGUEZ, MARK ANTHONY (MA PSYCH LMFT135452)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MA PSYCH LMFT135452
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6505 BRIDGEPORT LN
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-3404
Mailing Address - Country:US
Mailing Address - Phone:661-865-2352
Mailing Address - Fax:
Practice Address - Street 1:1522 18TH ST STE 300
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-4433
Practice Address - Country:US
Practice Address - Phone:661-865-2352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT135452106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist