Provider Demographics
NPI:1346320447
Name:WARE, DOMINIQUE HARMON (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:HARMON
Last Name:WARE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:HARMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:108 E PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 E PONCE DE LEON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2512
Practice Address - Country:US
Practice Address - Phone:678-561-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1041C0700X1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW003395OtherCLINICAL SOCIAL WORKER