Provider Demographics
NPI:1407191919
Name:DOMINGUEZ, STACY (BCBA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3731 6TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4383
Mailing Address - Country:US
Mailing Address - Phone:619-278-0884
Mailing Address - Fax:
Practice Address - Street 1:725 S MESA HILLS DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-5568
Practice Address - Country:US
Practice Address - Phone:915-760-4147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBCBA: 1-13-12777103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst