Provider Demographics
NPI:1003474388
Name:ROMANO ESTRADA, DOMI AVILIA
Entity Type:Individual
Prefix:
First Name:DOMI
Middle Name:AVILIA
Last Name:ROMANO ESTRADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 NE 171ST ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-2918
Mailing Address - Country:US
Mailing Address - Phone:786-312-6357
Mailing Address - Fax:
Practice Address - Street 1:1570 NE 171ST ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-2918
Practice Address - Country:US
Practice Address - Phone:786-312-6357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-86835106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician