Provider Demographics
NPI:1720862824
Name:DOMINGUEZ, JUAN J
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:J
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 1:6320 CANOGA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-2560
Mailing Address - Country:US
Mailing Address - Phone:818-600-8758
Mailing Address - Fax:
Practice Address - Street 1:6320 CANOGA AVE STE 101
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-2560
Practice Address - Country:US
Practice Address - Phone:818-600-8758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11939817103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA823891776Other0000000