Basic Information
| Provider Information | |||||||||
| NPI: | 1992179659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE-DOMINGUEZ | ||||||||
| FirstName: | MARY ELLEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | MARY ELLEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1901 S 24TH AVE | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785396533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562897025 | ||||||||
| FaxNumber: | 9562897257 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 S 24TH AVE | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785396533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562897025 | ||||||||
| FaxNumber: | 9562897257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2015 | ||||||||
| LastUpdateDate: | 11/18/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 64939 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 00R945 | 01 | TX | MEDICARE | OTHER | 138708611 | 05 | TX | MEDICAID | 138708613 | 05 | TX | MEDICAID |