Provider Demographics
NPI:1376104091
Name:DOMINGUES, RAYNER
Entity Type:Individual
Prefix:
First Name:RAYNER
Middle Name:
Last Name:DOMINGUES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18420 NW 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-3202
Mailing Address - Country:US
Mailing Address - Phone:201-647-9678
Mailing Address - Fax:
Practice Address - Street 1:18420 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-3202
Practice Address - Country:US
Practice Address - Phone:201-647-9678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-69190106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician