Provider Demographics
NPI:1689260051
Name:DOMENECH, ELSA
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:DOMENECH
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 1:785 LILAC DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-3438
Mailing Address - Country:US
Mailing Address - Phone:786-325-9478
Mailing Address - Fax:
Practice Address - Street 1:785 LILAC DR
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-3438
Practice Address - Country:US
Practice Address - Phone:786-325-9478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL569390106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician