Provider Demographics
NPI:1811232754
Name:AMESCUA, DOMINIQUE (LMSW, CI)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:AMESCUA
Suffix:
Gender:F
Credentials:LMSW, CI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8402 CROSS PARK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-4595
Mailing Address - Country:US
Mailing Address - Phone:512-697-8665
Mailing Address - Fax:
Practice Address - Street 1:8402 CROSS PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-4595
Practice Address - Country:US
Practice Address - Phone:512-697-8665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17559101YA0400X
TX565941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)