Provider Demographics
NPI:1679205074
Name:BROADNAX, DOMINIQUE VICTORIA
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:VICTORIA
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 CENTENNIAL DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3283
Mailing Address - Country:US
Mailing Address - Phone:619-928-8393
Mailing Address - Fax:
Practice Address - Street 1:964 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3283
Practice Address - Country:US
Practice Address - Phone:619-928-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-26
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health