1235424573 NPI number — MR. JOSE DOMINGUEZ BEHAVIOR ANALYST

Table of content: MR. JOSE DOMINGUEZ BEHAVIOR ANALYST (NPI 1235424573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235424573 NPI number — MR. JOSE DOMINGUEZ BEHAVIOR ANALYST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINGUEZ
Provider First Name:
JOSE
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BEHAVIOR ANALYST
Provider Gender Code:
M

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:
1235424573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2410 NW 102ND TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33026-1824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-483-3947
Provider Business Mailing Address Fax Number:
954-345-8483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3691 NW 124TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAL SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33065-2409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-345-8483
Provider Business Practice Location Address Fax Number:
954-345-8483
Provider Enumeration Date:
06/15/2011

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:  0-02-0445 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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