Provider Demographics
NPI:1013715820
Name:HARPER, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:HARPER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 HENDRICKS RD
Mailing Address - Street 2:
Mailing Address - City:ROBBINS
Mailing Address - State:IL
Mailing Address - Zip Code:60472-2231
Mailing Address - Country:US
Mailing Address - Phone:708-631-5402
Mailing Address - Fax:
Practice Address - Street 1:4840 GRASSELLI ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3503
Practice Address - Country:US
Practice Address - Phone:219-397-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-25-415010106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician