Provider Demographics
NPI:1992680847
Name:MERA DOMINGUEZ, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MERA DOMINGUEZ
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 CANBERRA CIR APT 204
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-3519
Mailing Address - Country:US
Mailing Address - Phone:561-489-9475
Mailing Address - Fax:
Practice Address - Street 1:901 LOCKE ST
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-4796
Practice Address - Country:US
Practice Address - Phone:863-296-8495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLBACB1224347106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst