Provider Demographics
NPI:1013498831
Name:SMITH, DOMINIQUE DENIECE
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:DENIECE
Last Name:SMITH
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 1:610 E AVENUE D
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-7143
Mailing Address - Country:US
Mailing Address - Phone:954-513-7130
Mailing Address - Fax:
Practice Address - Street 1:506 VAN NESS ST
Practice Address - Street 2:
Practice Address - City:WINTERS
Practice Address - State:TX
Practice Address - Zip Code:79567-4724
Practice Address - Country:US
Practice Address - Phone:325-754-4566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211177224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant