Provider Demographics
NPI:1902390610
Name:GRAHAM, DOMINIQUE (DPT)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 GATEHOUSE RD STE 300W3080
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1252
Mailing Address - Country:US
Mailing Address - Phone:703-289-8684
Mailing Address - Fax:
Practice Address - Street 1:6201 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2626
Practice Address - Country:US
Practice Address - Phone:703-263-2095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist