Provider Demographics
NPI:1558184846
Name:DOMINGUEZ SANTANA, PEDRO ENRIQUE
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:ENRIQUE
Last Name:DOMINGUEZ SANTANA
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 1:777 SW 111TH WAY APT 203
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-6929
Mailing Address - Country:US
Mailing Address - Phone:954-446-4391
Mailing Address - Fax:
Practice Address - Street 1:777SW 111TH WAY
Practice Address - Street 2:APTO 203 BUILDING 8
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-3302
Practice Address - Country:US
Practice Address - Phone:954-446-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician