1073179628 NPI number — MRS. VICTORIA C DOMANGUE BCBA, LBA

Table of content: MRS. VICTORIA C DOMANGUE BCBA, LBA (NPI 1073179628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073179628 NPI number — MRS. VICTORIA C DOMANGUE BCBA, LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMANGUE
Provider First Name:
VICTORIA
Provider Middle Name:
C
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA, LBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073179628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 PICONE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUMA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70363-7051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-860-3752
Provider Business Mailing Address Fax Number:
985-208-3051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 PICONE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUMA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70363-7051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-860-3752
Provider Business Practice Location Address Fax Number:
985-208-3051
Provider Enumeration Date:
05/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  L-369 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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