Basic Information
| Provider Information | |||||||||
| NPI: | 1740519651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMINGUE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 363 HIGHLAND AVE. | ||||||||
| Address2: | SOUTHCOAST CENTER FOR CANCER CARE | ||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086797814 | ||||||||
| FaxNumber: | 5086797881 | ||||||||
| Practice Location | |||||||||
| Address1: | 363 HIGHLAND AVE. | ||||||||
| Address2: | SOUTHCOAST CENTER FOR CANCER CARE | ||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086797814 | ||||||||
| FaxNumber: | 5086797881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2009 | ||||||||
| LastUpdateDate: | 12/24/2009 | ||||||||
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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 | 1041C0700X | 1030762 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.