Healthcare Provider Details

I. General information

NPI: 1215606652
Provider Name (Legal Business Name): ERIK DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 ORLANDO CENTRAL PKWY STE 480
ORLANDO FL
32809-5785
US

IV. Provider business mailing address

1707 ORLANDO CENTRAL PKWY STE 480
ORLANDO FL
32809-5785
US

V. Phone/Fax

Practice location:
  • Phone: 407-382-9079
  • Fax:
Mailing address:
  • Phone: 407-382-9079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: