Provider Demographics
NPI:1699585919
Name:FUENTES DOMINGUEZ, LUIS MIGUEL
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:MIGUEL
Last Name:FUENTES 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 1:7001 SANDHURST DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-5946
Mailing Address - Country:US
Mailing Address - Phone:813-730-6178
Mailing Address - Fax:
Practice Address - Street 1:7001 SANDHURST DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-5946
Practice Address - Country:US
Practice Address - Phone:813-730-6178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician