Provider Demographics
NPI:1194595561
Name:DOMINGUEZ, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-2611
Mailing Address - Country:US
Mailing Address - Phone:308-765-8971
Mailing Address - Fax:
Practice Address - Street 1:1145 M ST
Practice Address - Street 2:
Practice Address - City:GERING
Practice Address - State:NE
Practice Address - Zip Code:69341-2835
Practice Address - Country:US
Practice Address - Phone:308-633-3703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health