Provider Demographics
NPI:1205382983
Name:DOMINGUEZ, HAROLYN
Entity Type:Individual
Prefix:
First Name:HAROLYN
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 1:7250 NW 177TH ST
Mailing Address - Street 2:APT 103
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-6236
Mailing Address - Country:US
Mailing Address - Phone:305-200-2086
Mailing Address - Fax:
Practice Address - Street 1:7250 NW 177TH ST
Practice Address - Street 2:APT 103
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-6236
Practice Address - Country:US
Practice Address - Phone:305-200-2086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD552320948790247200000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other