Provider Demographics
NPI:1871103390
Name:DOMINGUEZ, CAROLINA MAITE
Entity type:Individual
Prefix:
First Name:CAROLINA
Middle Name:MAITE
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 1:5355 PAGE BLVD # MO63112
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3414
Mailing Address - Country:US
Mailing Address - Phone:314-361-2222
Mailing Address - Fax:
Practice Address - Street 1:5355 PAGE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-3414
Practice Address - Country:US
Practice Address - Phone:314-361-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1942449194Other1942449194