Provider Demographics
NPI:1558957977
Name:ACOSTA DOMINGUEZ, MARIA EUGENIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:EUGENIA
Last Name:ACOSTA DOMINGUEZ
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 1:2615 RIDGETOP WAY
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-4226
Mailing Address - Country:US
Mailing Address - Phone:813-369-5926
Mailing Address - Fax:
Practice Address - Street 1:4515 ASHFORD DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-1148
Practice Address - Country:US
Practice Address - Phone:786-278-7655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLRBT-20-148965106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist