Provider Demographics
NPI:1508382516
Name:VASQUEZ, DOMINIQUE JAGELKA (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:JAGELKA
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-2021
Mailing Address - Country:US
Mailing Address - Phone:617-774-0453
Mailing Address - Fax:
Practice Address - Street 1:608 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-2021
Practice Address - Country:US
Practice Address - Phone:617-774-0453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118443235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist