Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | X-07173 | NM |
NPI | 1003126954 |
---|---|
Provider Name | Sandra Dominguez |
First Address | Hatch, NM 87937-0370 |
Second Address | Las Cruces, NM 88012-9776 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2010 |
Last Update Date | 13/10/2010 |