Provider Demographics
NPI:1508321340
Name:DOMINGUEZ, GUILLERMO
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:DOMINGUEZ
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 1:16721 FM 1485 RD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77306-8957
Mailing Address - Country:US
Mailing Address - Phone:832-552-2771
Mailing Address - Fax:
Practice Address - Street 1:16721 FM 1485 RD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77306-8957
Practice Address - Country:US
Practice Address - Phone:832-552-2771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician