Provider Demographics
NPI:1124710074
Name:TAVAREZ-DOMINGUEZ, JUNIOR
Entity type:Individual
Prefix:
First Name:JUNIOR
Middle Name:
Last Name:TAVAREZ-DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9219 92ND AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-3002
Mailing Address - Country:US
Mailing Address - Phone:718-916-5071
Mailing Address - Fax:
Practice Address - Street 1:9219 92ND AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-3002
Practice Address - Country:US
Practice Address - Phone:718-916-5071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118569-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty