Provider Demographics
NPI:1972658748
Name:DOUGLAS, DOMINIQUE KAY
Entity Type:Individual
Prefix:MISS
First Name:DOMINIQUE
Middle Name:KAY
Last Name:DOUGLAS
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 1:106 MOSS LN
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4080
Mailing Address - Country:US
Mailing Address - Phone:985-857-3615
Mailing Address - Fax:985-857-3706
Practice Address - Street 1:106 MOSS LN
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4080
Practice Address - Country:US
Practice Address - Phone:985-857-3615
Practice Address - Fax:985-857-3706
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health