Provider Demographics
NPI:1568819134
Name:DOMINGUEZ VAZQUEZ, CARMEN LE HANG
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:LE HANG
Last Name:DOMINGUEZ VAZQUEZ
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 1:572 W 65TH DR
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6559
Mailing Address - Country:US
Mailing Address - Phone:786-416-3594
Mailing Address - Fax:
Practice Address - Street 1:572 W 65TH DR
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6559
Practice Address - Country:US
Practice Address - Phone:786-416-3594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician