Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 0859 | NM |
Y | 103G00000X | Clinical Psychologist | 0859 | NM |
Y | 103TC0700X | Clinical Psychologist | 0859 | NM |
NPI | 1437346566 |
---|---|
Provider Name | Thomas Paul Dominguez |
First Address | Albuquerque, NM 87120-6238 |
Second Address | Albuquerque, NM 87110-6443 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2007 |
Last Update Date | 02/10/2007 |