Provider Demographics
NPI:1780831065
Name:DOSEDO, DOMINIQUE JODIE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:JODIE
Last Name:DOSEDO
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 1:720 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4250
Mailing Address - Country:US
Mailing Address - Phone:575-454-8265
Mailing Address - Fax:
Practice Address - Street 1:720 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4250
Practice Address - Country:US
Practice Address - Phone:575-454-8265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT - 0113251101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health