Provider Demographics
NPI:1497484018
Name:FICKLING, DOMINQUE ANDRIESE (LCAT)
Entity Type:Individual
Prefix:
First Name:DOMINQUE
Middle Name:ANDRIESE
Last Name:FICKLING
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 CEDAR HILL AVE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-2424
Mailing Address - Country:US
Mailing Address - Phone:917-736-4507
Mailing Address - Fax:
Practice Address - Street 1:149 CEDAR HILL AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-2424
Practice Address - Country:US
Practice Address - Phone:917-736-4507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002676-01225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist