Provider Demographics
NPI:1699036798
Name:DOMINIQUE, KATHLEEN
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:SAINVIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:770 LOWER MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:EFFORT
Mailing Address - State:PA
Mailing Address - Zip Code:18330-8139
Mailing Address - Country:US
Mailing Address - Phone:718-576-2091
Mailing Address - Fax:
Practice Address - Street 1:1800 ALBEMARLE RD APT B12
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-8023
Practice Address - Country:US
Practice Address - Phone:718-576-2091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY578421111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist