Basic Information
| Provider Information | |||||||||
| NPI: | 1710512736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOWNSEND | ||||||||
| FirstName: | DOMINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1196 3RD AVE STE C | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919113131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194274661 | ||||||||
| FaxNumber: | 6194267849 | ||||||||
| Practice Location | |||||||||
| Address1: | 1196 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919113131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194274661 | ||||||||
| FaxNumber: | 6194267849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2020 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.