Provider Demographics
NPI:1629614862
Name:DOMINGUEZ, JOSE A (MEDU)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:A
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MEDU
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 LOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-1813
Mailing Address - Country:US
Mailing Address - Phone:978-691-5348
Mailing Address - Fax:
Practice Address - Street 1:22 OLD CANAL DR
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-2730
Practice Address - Country:US
Practice Address - Phone:978-452-5755
Practice Address - Fax:978-970-0713
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional