Provider Demographics
NPI:1497387807
Name:GIESE, DOMINIQUE (BCABA)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:GIESE
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 N BRUNS LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4613
Mailing Address - Country:US
Mailing Address - Phone:217-793-2100
Mailing Address - Fax:850-602-6932
Practice Address - Street 1:232 N BRUNS LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4613
Practice Address - Country:US
Practice Address - Phone:217-793-2100
Practice Address - Fax:850-602-6932
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BACB-0-21-11871106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst