Provider Demographics
NPI:1689233751
Name:DOMINGUEZ, CARLOS RAFAEL
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:RAFAEL
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 1:12995 S CLEVELAND AVE STE 216
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3807
Mailing Address - Country:US
Mailing Address - Phone:305-490-7178
Mailing Address - Fax:
Practice Address - Street 1:12995 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3890
Practice Address - Country:US
Practice Address - Phone:305-490-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11165103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty