Provider Demographics
NPI:1669524179
Name:MACCURTIN, DOMINIQUE THERESE (LMFT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:THERESE
Last Name:MACCURTIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:THERESE
Other - Last Name:DENARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:1200 D STREET #7
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:707-343-5152
Mailing Address - Fax:
Practice Address - Street 1:1200 D STREET #7
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-343-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT39835106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist