Provider Demographics
NPI:1154978989
Name:GARGALLO DOMINGUEZ, ARYS LEYDA
Entity type:Individual
Prefix:
First Name:ARYS
Middle Name:LEYDA
Last Name:GARGALLO 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 1:4680 NW 107TH AVE APT 1508
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4251
Mailing Address - Country:US
Mailing Address - Phone:786-424-2626
Mailing Address - Fax:
Practice Address - Street 1:4680 NW 107TH AVE APT 1508
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4251
Practice Address - Country:US
Practice Address - Phone:786-424-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL1-21-57170103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104537900Medicaid