Provider Demographics
NPI:1225502065
Name:WILSON, DOMINIQUE (DPT, CLT, CMTPT-DN)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPT, CLT, CMTPT-DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6323 GEORGIA AVE NW # 56167
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-1101
Mailing Address - Country:US
Mailing Address - Phone:202-486-1631
Mailing Address - Fax:
Practice Address - Street 1:6323 GEORGIA AVE NW # 56167
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1101
Practice Address - Country:US
Practice Address - Phone:202-486-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207926225100000X
MD27058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist