Healthcare Provider Details

I. General information

NPI: 1063343424
Provider Name (Legal Business Name): CARLOS MIGUEL DOMENECH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14385 SW 45TH TER
MIAMI FL
33175-6844
US

IV. Provider business mailing address

14385 SW 45TH TER
MIAMI FL
33175-6844
US

V. Phone/Fax

Practice location:
  • Phone: 786-310-9482
  • Fax:
Mailing address:
  • Phone: 786-310-9482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberD552-113-06-424-0
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: