Provider Demographics
NPI:1821853250
Name:HARRY, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:HARRY
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:PO BOX 7092
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30065-1092
Mailing Address - Country:US
Mailing Address - Phone:770-376-7381
Mailing Address - Fax:
Practice Address - Street 1:6425 POWERS FERRY RD STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2908
Practice Address - Country:US
Practice Address - Phone:866-841-1906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0108791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical