MEDICARE: CARLA NICOLE DOMIGUEZ M.A. - C.C.C., SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	35721	CA

General Provider Information

NPI Number	:	1326890500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA NICOLE DOMIGUEZ M.A. - C.C.C., SLP

Provider Business Mailing Address
First Line	:	3280 E FAIRFAX RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-4206
Country	:	US
Telephone Number	:	440-334-8122
Fax Number	:

Provider Business Practice Location Address
First Line	:	3280 E FAIRFAX RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-4206
Country	:	US
Telephone Number	:	440-334-8122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2024
Last Update Date	:	04/02/2024

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