Provider Demographics
NPI:1770829947
Name:DOLIVO, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:DOLIVO
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 1:415 NEPONSET AVE
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 NEPONSET AVE
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3168
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health