Healthcare Provider Details

I. General information

NPI: 1689339657
Provider Name (Legal Business Name): EDITH DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 08/26/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 W CHAPMAN AVE
ORANGE CA
92868-2647
US

IV. Provider business mailing address

2050 W CHAPMAN AVE
ORANGE CA
92868-2647
US

V. Phone/Fax

Practice location:
  • Phone: 949-989-6932
  • Fax:
Mailing address:
  • Phone: 949-989-6932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: