Provider Demographics
NPI:1356005748
Name:DOMINGUEZ, CAROLINE LYDIA
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:LYDIA
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 1:1420 SW 31ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-2828
Mailing Address - Country:US
Mailing Address - Phone:954-675-9438
Mailing Address - Fax:
Practice Address - Street 1:1001 W CYPRESS CREEK RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1900
Practice Address - Country:US
Practice Address - Phone:954-675-9438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB702836106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician