Provider Demographics
NPI:1023346079
Name:DOMINGUEZ, ALBERT JOE (MBHM)
Entity type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:JOE
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MBHM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 HOME TER
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-1285
Mailing Address - Country:US
Mailing Address - Phone:909-524-2863
Mailing Address - Fax:909-629-0058
Practice Address - Street 1:1837 HOME TERRACE DR.
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-1285
Practice Address - Country:US
Practice Address - Phone:909-524-2863
Practice Address - Fax:909-629-0058
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor