Provider Demographics
NPI:1164248845
Name:DIAZ DOMINGUEZ, GABRIELA
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
Last Name:DIAZ 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 1:4570 NW 79TH AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6317
Mailing Address - Country:US
Mailing Address - Phone:786-930-2182
Mailing Address - Fax:
Practice Address - Street 1:4570 NW 79TH AVE APT 1B
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6317
Practice Address - Country:US
Practice Address - Phone:786-930-2182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician