Provider Demographics
NPI:1609044783
Name:RANDALL, DOMONIQUE
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:DOMONIQUE
Other - Middle Name:
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, BCBA
Mailing Address - Street 1:26006 OAKRIDGE DR.
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380
Mailing Address - Country:US
Mailing Address - Phone:832-358-2655
Mailing Address - Fax:832-358-3530
Practice Address - Street 1:26006 OAKRIDGE DR.
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380
Practice Address - Country:US
Practice Address - Phone:832-358-2655
Practice Address - Fax:832-358-3530
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-00-0350174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist