MEDICARE: LUIS E DOMINGUEZ LEDESMA RBT

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-20-129550	FL

General Provider Information

NPI Number	:	1932715067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS E DOMINGUEZ LEDESMA RBT

Provider Business Mailing Address
First Line	:	10756 N KENDALL DR APT J1
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33176-1428
Country	:	US
Telephone Number	:	786-339-0132
Fax Number	:	561-828-3124

Provider Business Practice Location Address
First Line	:	5845 SW 144TH CIRCLE PL
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33183-1073
Country	:	US
Telephone Number	:	305-776-0728
Fax Number	:	561-828-3124

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

Provider Enumeration Date	:	09/23/2020
Last Update Date	:	09/23/2020

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Directions to “ LUIS E DOMINGUEZ LEDESMA RBT” Practice Location

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