Provider Demographics
NPI:1093010647
Name:CONDEVAUX, DOMINIQUE (LAC, LPC, MAC, NCC)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:CONDEVAUX
Suffix:
Gender:F
Credentials:LAC, LPC, MAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12101 E 2ND AVE
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-8327
Mailing Address - Country:US
Mailing Address - Phone:303-819-7788
Mailing Address - Fax:
Practice Address - Street 1:12101 E 2ND AVE
Practice Address - Street 2:SUITE 201B
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-8327
Practice Address - Country:US
Practice Address - Phone:303-819-7788
Practice Address - Fax:720-216-0273
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000219101YA0400X
COLPC.0011288101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health