Provider Demographics
NPI:1134901333
Name:WHITE, DOMINIQUE (PHD)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 N SEPULVEDA BLVD UNIT 212
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90267-8208
Mailing Address - Country:US
Mailing Address - Phone:310-564-6170
Mailing Address - Fax:
Practice Address - Street 1:3608 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-3234
Practice Address - Country:US
Practice Address - Phone:310-564-6170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32743103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist