Provider Demographics
NPI:1093581753
Name:BERMEOSOLO DOMINGUEZ, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:BERMEOSOLO DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15045 SW 127TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6322
Mailing Address - Country:US
Mailing Address - Phone:786-273-2563
Mailing Address - Fax:
Practice Address - Street 1:15045 SW 127TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6322
Practice Address - Country:US
Practice Address - Phone:786-273-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-311035106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician