Provider Demographics
NPI:1407470925
Name:WASHINGTON, DOMINQUE
Entity Type:Individual
Prefix:
First Name:DOMINQUE
Middle Name:
Last Name:WASHINGTON
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 1:11905 BOWMAN DR STE 507
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-7344
Mailing Address - Country:US
Mailing Address - Phone:540-395-9962
Mailing Address - Fax:
Practice Address - Street 1:11905 BOWMAN DR STE 507
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-7344
Practice Address - Country:US
Practice Address - Phone:540-395-9962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A