Provider Demographics
NPI:1689856130
Name:KIEFER, DOMINIQUE BLANCHE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:BLANCHE
Last Name:KIEFER
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 1:11460 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6030
Mailing Address - Country:US
Mailing Address - Phone:310-337-7115
Mailing Address - Fax:
Practice Address - Street 1:11605 WASHINGTON PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5013
Practice Address - Country:US
Practice Address - Phone:310-337-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics