Provider Demographics
NPI:1043322027
Name:DOMINGUEZ, BRENDA L (LPC)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:L
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:BRENDA
Other - Middle Name:LYNN
Other - Last Name:BOYCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4502 STARKEY RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8539
Mailing Address - Country:US
Mailing Address - Phone:540-772-1263
Mailing Address - Fax:540-772-1264
Practice Address - Street 1:4502 STARKEY RD
Practice Address - Street 2:SUITE 208
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-8539
Practice Address - Country:US
Practice Address - Phone:540-772-1263
Practice Address - Fax:540-772-1264
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003123101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
163443OtherANTHEM
2095633OtherCIGNA
VA010125766Medicaid