Provider Demographics
NPI:1235401449
Name:DOR, DOMINIQUE (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:
Last Name:DOR
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 W WHEATLAND RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-4515
Mailing Address - Country:US
Mailing Address - Phone:972-709-1180
Mailing Address - Fax:972-709-1180
Practice Address - Street 1:549 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4515
Practice Address - Country:US
Practice Address - Phone:972-709-1180
Practice Address - Fax:972-709-1180
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66598101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health