Healthcare Provider Details

I. General information

NPI: 1023507886
Provider Name (Legal Business Name): KEILA DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2736 HOLLYWOOD BLVD
HOLLYWOOD FL
33020-4808
US

IV. Provider business mailing address

2736 HOLLYWOOD BLVD
HOLLYWOOD FL
33020-4808
US

V. Phone/Fax

Practice location:
  • Phone: 954-603-1881
  • Fax:
Mailing address:
  • Phone: 954-603-1881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI4893
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: