Provider Demographics
NPI:1982179669
Name:DOMINO, LAUREL (BCBA)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:DOMINO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 LAKE COOK RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5649
Mailing Address - Country:US
Mailing Address - Phone:847-498-5437
Mailing Address - Fax:847-498-5438
Practice Address - Street 1:2979 PGA BLVD # 200
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-2911
Practice Address - Country:US
Practice Address - Phone:813-981-0815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-45053103K00000X
ILRBT-18-67044106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst