Provider Demographics
NPI:1265678502
Name:CLARK, DOMINIQUE JOLIE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:JOLIE
Last Name:CLARK
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 1:681 BEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1951
Mailing Address - Country:US
Mailing Address - Phone:240-417-9810
Mailing Address - Fax:
Practice Address - Street 1:12201 WALLACE LANDING CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-7957
Practice Address - Country:US
Practice Address - Phone:240-417-9810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009176235Z00000X
IN22004686A235Z00000X
MD05036235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist