Provider Demographics
NPI:1083329577
Name:WALKER, DOMINIQUE L
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:L
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27090 ADELANTO DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-8956
Mailing Address - Country:US
Mailing Address - Phone:562-414-7565
Mailing Address - Fax:
Practice Address - Street 1:495 E RINCON ST STE 209
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1379
Practice Address - Country:US
Practice Address - Phone:562-821-1491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136645106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist