Provider Demographics
NPI:1194025155
Name:OPUTA, DOMINIQUE MARIA (MA)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MARIA
Last Name:OPUTA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 PALMER CT
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-4810
Mailing Address - Country:US
Mailing Address - Phone:313-673-0763
Mailing Address - Fax:
Practice Address - Street 1:500 N WEST ST
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2366
Practice Address - Country:US
Practice Address - Phone:215-345-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007345101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health