Provider Demographics
NPI:1144739145
Name:DOMINGUE, COURTNEY LOUISE (MA, BCBA, LBA, IBA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LOUISE
Last Name:DOMINGUE
Suffix:
Gender:F
Credentials:MA, BCBA, LBA, IBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2253 CROSSBOW ST
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-9315
Mailing Address - Country:US
Mailing Address - Phone:210-290-6575
Mailing Address - Fax:
Practice Address - Street 1:2253 CROSSBOW ST
Practice Address - Street 2:
Practice Address - City:MINNEOLA
Practice Address - State:FL
Practice Address - Zip Code:34715-9315
Practice Address - Country:US
Practice Address - Phone:210-290-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-27891103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1067OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION - LICENSED BEHAVIOR ANALYST
VA0133003246OtherBOARD OF MEDICINE - LICENSED BEHAVIOR ANALYST
27502033OtherINTERNATIONAL BEHAVIOR ANALYSIS ORGANIZATION - INTERNATIONAL BEHAVIOR ANALYST
1-17-27891OtherBACB - BOARD CERTIFIED BEHAVIOR ANALYST