Provider Demographics
NPI:1417655879
Name:DOMINGUEZ CABELLO, LISAIDA
Entity Type:Individual
Prefix:
First Name:LISAIDA
Middle Name:
Last Name:DOMINGUEZ CABELLO
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 1:8438 SW 38TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3259
Mailing Address - Country:US
Mailing Address - Phone:786-326-2507
Mailing Address - Fax:
Practice Address - Street 1:8438 SW 38TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3259
Practice Address - Country:US
Practice Address - Phone:786-326-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-122463106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst