Healthcare Provider Details

I. General information

NPI: 1356151716
Provider Name (Legal Business Name): MICHAEL DOMINGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 SW ARCTIC DR
BEAVERTON OR
97005-9447
US

IV. Provider business mailing address

1555 COBURG RD APT 38
EUGENE OR
97401-4880
US

V. Phone/Fax

Practice location:
  • Phone: 458-310-3150
  • Fax:
Mailing address:
  • Phone: 541-912-6066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: