Provider Demographics
NPI:1154051431
Name:DOMINGUEZ CHAVEZ, YUDELKIS (RBT-20-127599)
Entity Type:Individual
Prefix:
First Name:YUDELKIS
Middle Name:
Last Name:DOMINGUEZ CHAVEZ
Suffix:
Gender:F
Credentials:RBT-20-127599
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 NE 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-1602
Mailing Address - Country:US
Mailing Address - Phone:786-731-1505
Mailing Address - Fax:
Practice Address - Street 1:1332 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-1602
Practice Address - Country:US
Practice Address - Phone:786-731-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-127599106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty