1780219683 NPI number — GABRIELLE MIA DOMINGUEZ MA, BCBA

Table of content: GABRIELLE MIA DOMINGUEZ MA, BCBA (NPI 1780219683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780219683 NPI number — GABRIELLE MIA DOMINGUEZ MA, BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINGUEZ
Provider First Name:
GABRIELLE
Provider Middle Name:
MIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, BCBA
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:
1780219683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 DEPAUW BLVD STE 3070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-6135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-324-0885
Provider Business Mailing Address Fax Number:
317-520-8200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12322 W REYHER FARMS LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARANA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85653-7612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-277-2190
Provider Business Practice Location Address Fax Number:
317-520-8200
Provider Enumeration Date:
03/11/2020

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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