Provider Demographics
NPI:1821848284
Name:WILCOX, DOMINIQUE M (SOCIAL WORK)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:M
Last Name:WILCOX
Suffix:
Gender:F
Credentials:SOCIAL WORK
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:M
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28 BARDIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14615-3520
Mailing Address - Country:US
Mailing Address - Phone:585-957-8646
Mailing Address - Fax:
Practice Address - Street 1:175 N WINTON RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-1936
Practice Address - Country:US
Practice Address - Phone:585-410-3370
Practice Address - Fax:585-978-7217
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health