Provider Demographics
NPI:1043696982
Name:DAVIS-WARNER, DOMINIQUE (LPC)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:DAVIS-WARNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337B SPRINGER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-7902
Mailing Address - Country:US
Mailing Address - Phone:601-415-2313
Mailing Address - Fax:
Practice Address - Street 1:1337B SPRINGER RIDGE RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-7902
Practice Address - Country:US
Practice Address - Phone:601-415-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178010889101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional