Provider Demographics
NPI:1417663659
Name:CORREA, DOMINIQUE (LCMHCA)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:CORREA
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:206 FAIR OAKS LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-3178
Mailing Address - Country:US
Mailing Address - Phone:984-244-1695
Mailing Address - Fax:
Practice Address - Street 1:206 FAIR OAKS LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-3178
Practice Address - Country:US
Practice Address - Phone:336-745-7179
Practice Address - Fax:336-293-4020
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18326101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health