Provider Demographics
NPI:1922255397
Name:DOMINGUEZ, ILIANA
Entity Type:Individual
Prefix:
First Name:ILIANA
Middle Name:
Last Name: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 1:8600 SW 92ND ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7397
Mailing Address - Country:US
Mailing Address - Phone:305-279-2428
Mailing Address - Fax:305-596-9996
Practice Address - Street 1:8600 SW 92ND ST
Practice Address - Street 2:SUITE 204
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7397
Practice Address - Country:US
Practice Address - Phone:305-279-2428
Practice Address - Fax:305-596-9996
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2014-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 13334235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist