Healthcare Provider Details

I. General information

NPI: 1184280885
Provider Name (Legal Business Name): BREANNE DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 HUNT DR
NORMAL IL
61761-2192
US

IV. Provider business mailing address

1606 HUNT DR
NORMAL IL
61761-2192
US

V. Phone/Fax

Practice location:
  • Phone: 309-451-8888
  • Fax: 309-451-8989
Mailing address:
  • Phone: 309-451-8888
  • Fax: 309-451-8989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-35887
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number16-22497
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: