Provider Demographics
NPI:1407212285
Name:DOMINGUEZ, TERRA
Entity type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 MAYLAND DR STE S
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4648
Mailing Address - Country:US
Mailing Address - Phone:703-646-1076
Mailing Address - Fax:
Practice Address - Street 1:751 THORNTON WAY APT 305
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4428
Practice Address - Country:US
Practice Address - Phone:703-646-1076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-08
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040134071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical