Provider Demographics
NPI:1326523556
Name:DOMINGUEZ HORTA, LEYDIS
Entity Type:Individual
Prefix:MISS
First Name:LEYDIS
Middle Name:
Last Name:DOMINGUEZ HORTA
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 1:656 SW 5TH TER
Mailing Address - Street 2:
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034-4714
Mailing Address - Country:US
Mailing Address - Phone:786-399-1186
Mailing Address - Fax:
Practice Address - Street 1:656 SW 5TH TER
Practice Address - Street 2:
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034-4714
Practice Address - Country:US
Practice Address - Phone:786-399-1186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COBCABA-0-24-15047106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst