MEDICARE: STACY DOMINGUEZ BCBA

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	103K00000X	Behavior Analyst	BCBA: 1-13-12777	TX

General Provider Information

NPI Number	:	1407191919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY DOMINGUEZ BCBA

Provider Business Mailing Address
First Line	:	3731 6TH AVE STE 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4383
Country	:	US
Telephone Number	:	619-278-0884
Fax Number	:

Provider Business Practice Location Address
First Line	:	725 S MESA HILLS DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-5568
Country	:	US
Telephone Number	:	915-760-4147
Fax Number	:

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

Provider Enumeration Date	:	12/10/2012
Last Update Date	:	03/06/2013

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