Provider Demographics
NPI:1538173208
Name:DOMINGUEZ, MAYRA A (LCSW)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:A
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8261 NW 8 ST
Mailing Address - Street 2:APT 125
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3964
Mailing Address - Country:US
Mailing Address - Phone:786-282-7886
Mailing Address - Fax:
Practice Address - Street 1:8261 NW 8 ST
Practice Address - Street 2:APT 125
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-3964
Practice Address - Country:US
Practice Address - Phone:786-282-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL83421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical