Provider Demographics
NPI:1003152885
Name:DOMINIQUE, DARREL (PTA)
Entity Type:Individual
Prefix:MR
First Name:DARREL
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4526 PARK DR S
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-3328
Mailing Address - Country:US
Mailing Address - Phone:504-875-1216
Mailing Address - Fax:
Practice Address - Street 1:16 HEYMAN LN
Practice Address - Street 2:LEXINGTON HOUSE
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3523
Practice Address - Country:US
Practice Address - Phone:318-442-4364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-22
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA7461225200000X
TX2088460225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant