Provider Demographics
NPI:1790292506
Name:SAMPSON, DOMINIQUE LASHAE (LMFT)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LASHAE
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W 259TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-1908
Mailing Address - Country:US
Mailing Address - Phone:914-380-9220
Mailing Address - Fax:
Practice Address - Street 1:302 W 259TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-1908
Practice Address - Country:US
Practice Address - Phone:914-380-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
NY001596106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist