Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | R1423320321 | CA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | R1423320321 | CA |
NPI | 1043886054 |
---|---|
Provider Name | Patricia Gwen Dominguez |
First Address | Sacramento, CA 95838-3249 |
Second Address | Sacramento, CA 95838-3249 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2021 |
Last Update Date | 03/06/2021 |