Provider Demographics
NPI:1306392592
Name:PHINN, DOMINIQUE EBONY
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:EBONY
Last Name:PHINN
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 1:730 BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10474-6006
Mailing Address - Country:US
Mailing Address - Phone:718-542-1537
Mailing Address - Fax:
Practice Address - Street 1:730 BRYANT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10474-6006
Practice Address - Country:US
Practice Address - Phone:718-542-1537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP03319104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker