Provider Demographics
NPI:1407391303
Name:DOMINGUEZ, ALEXANDER (BCABA)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6635 BANNER LAKE CIR
Mailing Address - Street 2:APT. 4306
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-9388
Mailing Address - Country:US
Mailing Address - Phone:786-261-6810
Mailing Address - Fax:
Practice Address - Street 1:6635 BANNER LAKE CIR
Practice Address - Street 2:APT. 4306
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32821-9388
Practice Address - Country:US
Practice Address - Phone:786-261-6810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD552-000-91-321-0103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst