Provider Demographics
NPI:1225784556
Name:BLACK, DOMINIQUE JEROLDINE LEON (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:JEROLDINE LEON
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6216 SCOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONTON
Mailing Address - State:VA
Mailing Address - Zip Code:22724-2342
Mailing Address - Country:US
Mailing Address - Phone:540-219-3247
Mailing Address - Fax:
Practice Address - Street 1:6216 SCOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:JEFFERSONTON
Practice Address - State:VA
Practice Address - Zip Code:22724-2342
Practice Address - Country:US
Practice Address - Phone:540-219-3247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040137141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical