Healthcare Provider Details

I. General information

NPI: 1457095028
Provider Name (Legal Business Name): YESSENIA DOMINGUEZ- PEREA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DR STE 705-707
SANTA FE NM
87507-4929
US

IV. Provider business mailing address

5850 GRANITE PKWY STE 600
PLANO TX
75024-6753
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-9611
  • Fax:
Mailing address:
  • Phone: 469-694-1754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: