Provider Demographics
NPI:1912562497
Name:CAUTIVO, DOMINIQUE (AMFT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:CAUTIVO
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SIERRA MESA DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-2628
Mailing Address - Country:US
Mailing Address - Phone:408-768-8177
Mailing Address - Fax:
Practice Address - Street 1:1400 COLEMAN AVE
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-4309
Practice Address - Country:US
Practice Address - Phone:650-618-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA149470106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist