Provider Demographics
NPI:1295373850
Name:VEGA DOMINGUEZ, AIMEE
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:
Last Name:VEGA 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 1:1975 W 44TH PL APT 103
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-8412
Mailing Address - Country:US
Mailing Address - Phone:786-454-6627
Mailing Address - Fax:
Practice Address - Street 1:1975 W 44TH PL APT 103
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-8412
Practice Address - Country:US
Practice Address - Phone:786-454-6627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-98041106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104436400Medicaid