Provider Demographics
NPI:1255861928
Name:MANJARREZ DOMINGUEZ, PEDRO ARMANDO
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:ARMANDO
Last Name:MANJARREZ 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 1:101 PETER THEIN AVE UNIT D
Mailing Address - Street 2:
Mailing Address - City:BELGIUM
Mailing Address - State:WI
Mailing Address - Zip Code:53004-9520
Mailing Address - Country:US
Mailing Address - Phone:479-249-5624
Mailing Address - Fax:
Practice Address - Street 1:101 PETER THEIN AVE UNIT D
Practice Address - Street 2:
Practice Address - City:BELGIUM
Practice Address - State:WI
Practice Address - Zip Code:53004-9520
Practice Address - Country:US
Practice Address - Phone:479-249-5624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4424-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist