Provider Demographics
NPI:1003695081
Name:DOMINGUEZ, LIZBETH
Entity Type:Individual
Prefix:
First Name:LIZBETH
Middle Name:
Last Name:DOMINGUEZ
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 1:2479 UNIVERSITY AVE APT BSMNT
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-5642
Mailing Address - Country:US
Mailing Address - Phone:347-652-4065
Mailing Address - Fax:
Practice Address - Street 1:463 7TH AVE # 18TH
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-7604
Practice Address - Country:US
Practice Address - Phone:212-582-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst