Provider Demographics
NPI:1316739360
Name:PEREZ DOMINGUEZ, GLENDA RAQUEL (LCDA)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:RAQUEL
Last Name:PEREZ DOMINGUEZ
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 CALLE BAHIA
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-8942
Mailing Address - Country:US
Mailing Address - Phone:787-642-2581
Mailing Address - Fax:
Practice Address - Street 1:117 CALLE BAHIA
Practice Address - Street 2:
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623-8942
Practice Address - Country:US
Practice Address - Phone:787-642-2581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-17
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP1600X, 101YP2500X, 101YS0200X, 101YA0400X
PR4514101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)