Provider Demographics
NPI:1548801079
Name:DOMINGUEZ, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
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 1:14713 SW 177TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-6762
Mailing Address - Country:US
Mailing Address - Phone:786-343-8519
Mailing Address - Fax:
Practice Address - Street 1:14713 SW 177TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33187-6762
Practice Address - Country:US
Practice Address - Phone:786-343-8519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-06
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-100304106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD552-160-96-445-0Medicaid