=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558957977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA EUGENIA ACOSTA DOMINGUEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2020
-----------------------------------------------------
Last Update Date | 12/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4515 ASHFORD DR
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-1148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-278-7655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2615 RIDGETOP WAY
-----------------------------------------------------
City | VALRICO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33594-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-369-5926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Q00000X
-----------------------------------------------------
Taxonomy Name | Developmental Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-20-148965
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-24-77806
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------