Basic Information
| Provider Information | |||||||||
| NPI: | 1982179669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINO | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1161 LAKE COOK RD | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600155649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474985437 | ||||||||
| FaxNumber: | 8474985438 | ||||||||
| Practice Location | |||||||||
| Address1: | 2979 PGA BLVD # 200 | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334102911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139810815 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2018 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-20-45053 | FL | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | RBT-18-67044 | IL | Y |
No ID Information.