Provider Demographics
NPI:1275123622
Name:RAMOS, DOMINIQUE ALEXIS
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:ALEXIS
Last Name:RAMOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 HAVENER HOUSE WAY
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-3208
Mailing Address - Country:US
Mailing Address - Phone:703-492-2686
Mailing Address - Fax:
Practice Address - Street 1:7771 ASHTON AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2879
Practice Address - Country:US
Practice Address - Phone:703-492-2686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-19-99797106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician