Provider Demographics
NPI:1891520169
Name:DOMINGUEZ, MARY (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3526 NEWLAND ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6443
Mailing Address - Country:US
Mailing Address - Phone:979-777-5993
Mailing Address - Fax:
Practice Address - Street 1:12211 W ALAMEDA PKWY STE 105
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2825
Practice Address - Country:US
Practice Address - Phone:979-777-5993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0017339101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health