MEDICARE: DOMINIQUE AILEEN MEDINA

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

General Provider Information

NPI Number	:	1588541775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE AILEEN MEDINA

Provider Business Mailing Address
First Line	:	215 W FRANCIS ST
Second Line	:
City	:	BAYTOWN
State	:	TX
Zip	:	77520-2772
Country	:	US
Telephone Number	:	346-710-3510
Fax Number	:

Provider Business Practice Location Address
First Line	:	19701 KINGWOOD DR STE 8
Second Line	:
City	:	KINGWOOD
State	:	TX
Zip	:	77339-3775
Country	:	US
Telephone Number	:	281-973-0757
Fax Number	:

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

Provider Enumeration Date	:	08/19/2025
Last Update Date	:	08/19/2025

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Directions to “ DOMINIQUE AILEEN MEDINA ” Practice Location

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