MEDICARE: DOMINIQUE DOMINGO

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	106S00000X	Behavior Technician	RBT-22-200813	TX

General Provider Information

NPI Number	:	1457174385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE DOMINGO

Provider Business Mailing Address
First Line	:	1408 LAKE CITY LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77047-1252
Country	:	US
Telephone Number	:	518-466-0310
Fax Number	:

Provider Business Practice Location Address
First Line	:	1408 LAKE CITY LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77047-1252
Country	:	US
Telephone Number	:	518-466-0310
Fax Number	:

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

Provider Enumeration Date	:	11/07/2024
Last Update Date	:	11/07/2024

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Directions to “ DOMINIQUE DOMINGO ” Practice Location

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