Provider Demographics
NPI:1982323226
Name:BEATTY, DOMINI (MA, AMFT)
Entity type:Individual
Prefix:
First Name:DOMINI
Middle Name:
Last Name:BEATTY
Suffix:
Gender:F
Credentials:MA, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2664 LAS COLIMAS
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2331
Mailing Address - Country:US
Mailing Address - Phone:626-485-6257
Mailing Address - Fax:
Practice Address - Street 1:1201 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4203
Practice Address - Country:US
Practice Address - Phone:714-583-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131103106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist