Provider Demographics
NPI:1477326866
Name:HYNDMAN, DOMINIQUE NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NICOLE
Last Name:HYNDMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 ARTISAN PASS
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-0018
Mailing Address - Country:US
Mailing Address - Phone:260-705-4753
Mailing Address - Fax:
Practice Address - Street 1:178 ARTISAN PASS
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-0018
Practice Address - Country:US
Practice Address - Phone:260-705-4753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34010685A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical