Provider Demographics
NPI:1013766781
Name:GARCIA DOMINGUEZ, ADELAIDA BEATRIZ
Entity type:Individual
Prefix:
First Name:ADELAIDA
Middle Name:BEATRIZ
Last Name:GARCIA DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 VENTURES DR APT 1411
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-0180
Mailing Address - Country:US
Mailing Address - Phone:305-283-6728
Mailing Address - Fax:
Practice Address - Street 1:100 VENTURES DR APT 1411
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-0180
Practice Address - Country:US
Practice Address - Phone:305-283-6728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24-332079106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician