Healthcare Provider Details

I. General information

NPI: 1972412765
Provider Name (Legal Business Name): SELENA MARIA DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3067 SOUTHERN BLVD SE APT C
RIO RANCHO NM
87124-1998
US

IV. Provider business mailing address

3067 SOUTHERN BLVD SE
RIO RANCHO NM
87124-1998
US

V. Phone/Fax

Practice location:
  • Phone: 505-788-6770
  • Fax:
Mailing address:
  • Phone: 505-788-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number513378271
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: