Provider Demographics
NPI:1376991968
Name:DOMINGUEZ RODRIGUEZ, JOSE SR (MH-14987)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:DOMINGUEZ RODRIGUEZ
Suffix:SR
Gender:M
Credentials:MH-14987
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5816 SW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-3904
Mailing Address - Country:US
Mailing Address - Phone:786-451-4602
Mailing Address - Fax:
Practice Address - Street 1:5816 SW 5TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-3904
Practice Address - Country:US
Practice Address - Phone:786-451-4602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMH 1274101YM0800X
FLMH-14987103K00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst