Provider Demographics
NPI:1922727585
Name:DOMINGUEZ MARQUEZ, MELBISLEYDIS
Entity Type:Individual
Prefix:
First Name:MELBISLEYDIS
Middle Name:
Last Name:DOMINGUEZ MARQUEZ
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 1:352 GREENBRIER DR
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-1825
Mailing Address - Country:US
Mailing Address - Phone:561-838-6419
Mailing Address - Fax:
Practice Address - Street 1:1340 KENWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-7408
Practice Address - Country:US
Practice Address - Phone:561-358-1107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician