Provider Demographics
NPI:1235746975
Name:SCOTT, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5342 S WELLS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-6219
Mailing Address - Country:US
Mailing Address - Phone:708-631-1929
Mailing Address - Fax:
Practice Address - Street 1:5342 S WELLS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-6219
Practice Address - Country:US
Practice Address - Phone:708-631-1929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist