MEDICARE: VICTORIA NICOLE DOMENECH

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	106S00000X	Behavior Technician	RBT-23-281009	SC

General Provider Information

NPI Number	:	1831876218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA NICOLE DOMENECH

Provider Business Mailing Address
First Line	:	9345 BLUE HOUSE RD APT NO12205
Second Line	:
City	:	LADSON
State	:	SC
Zip	:	29456-4076
Country	:	US
Telephone Number	:	757-648-0331
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 ASHLEY PHOSPHATE RD
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29418-6405
Country	:	US
Telephone Number	:	843-813-1538
Fax Number	:

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

Provider Enumeration Date	:	06/28/2023
Last Update Date	:	07/19/2023

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