Provider Demographics
NPI:1154174266
Name:DOMINGUEZ DIAZ, ADDIEL
Entity type:Individual
Prefix:
First Name:ADDIEL
Middle Name:
Last Name:DOMINGUEZ DIAZ
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 1:11343 SW 228TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-7566
Mailing Address - Country:US
Mailing Address - Phone:786-838-5577
Mailing Address - Fax:
Practice Address - Street 1:11343 SW 228TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-7566
Practice Address - Country:US
Practice Address - Phone:786-838-5577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-320849106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty