Provider Demographics
NPI:1689148397
Name:DIJKHUIZEN, DOMINIQUE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:DIJKHUIZEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 COMMERCE AVE # 189
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-7059
Mailing Address - Country:US
Mailing Address - Phone:719-270-1722
Mailing Address - Fax:
Practice Address - Street 1:101 LANARK TRL
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-7513
Practice Address - Country:US
Practice Address - Phone:719-270-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1689148397261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health