MEDICARE: JOSE DOMINGUEZ RODRIGUEZ SR. MH-14987

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	PMH 1274	FL
2	103K00000X	Behavior Analyst	MH-14987	FL
3	101YM0800X	Mental Health Counselor	MH-14987	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376991968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE DOMINGUEZ RODRIGUEZ SR. MH-14987

Provider Business Mailing Address
First Line	:	5816 SW 5TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-3904
Country	:	US
Telephone Number	:	786-451-4602
Fax Number	:

Provider Business Practice Location Address
First Line	:	5816 SW 5TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-3904
Country	:	US
Telephone Number	:	786-451-4602
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2016
Last Update Date	:	03/17/2021

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