Provider Demographics
NPI:1932715067
Name:DOMINGUEZ LEDESMA, LUIS E (RBT)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:E
Last Name:DOMINGUEZ LEDESMA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10756 N KENDALL DR APT J1
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1428
Mailing Address - Country:US
Mailing Address - Phone:786-339-0132
Mailing Address - Fax:561-828-3124
Practice Address - Street 1:5845 SW 144TH CIRCLE PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-1073
Practice Address - Country:US
Practice Address - Phone:305-776-0728
Practice Address - Fax:561-828-3124
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-129550106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician