Provider Demographics
NPI:1780219683
Name:DOMINGUEZ, GABRIELLE MIA (MA, BCBA)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MIA
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MA, BCBA
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:12322 W REYHER FARMS LOOP
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-7612
Practice Address - Country:US
Practice Address - Phone:520-277-2190
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst