Basic Information
| Provider Information | |||||||||
| NPI: | 1568472025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMBOURIAN | ||||||||
| FirstName: | LORETTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 BRIARWOOD AVE SW APT 206 | ||||||||
| Address2: | |||||||||
| City: | FT PAYNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359678470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568454538 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2409 HOMER CLAYTON DR | ||||||||
| Address2: | |||||||||
| City: | GUNTERSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359762207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565823203 | ||||||||
| FaxNumber: | 2565823216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 51008777 | 01 | AL | BCBS | OTHER |