Provider Demographics
NPI:1689839649
Name:ACRE, DOMINIQUE MARIE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MARIE
Last Name:ACRE
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 1:1588 W YOSEMITE PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4871
Mailing Address - Country:US
Mailing Address - Phone:480-215-7938
Mailing Address - Fax:
Practice Address - Street 1:1588 W YOSEMITE PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4871
Practice Address - Country:US
Practice Address - Phone:480-215-7938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3293656103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool