Provider Demographics
NPI:1184280885
Name:DOMINGUEZ, BREANNE
Entity type:Individual
Prefix:
First Name:BREANNE
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 1:1606 HUNT DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2192
Mailing Address - Country:US
Mailing Address - Phone:309-451-8888
Mailing Address - Fax:309-451-8989
Practice Address - Street 1:1606 HUNT DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2192
Practice Address - Country:US
Practice Address - Phone:309-451-8888
Practice Address - Fax:309-451-8989
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16-22497106S00000X
IL1-19-35887103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician