Provider Demographics
NPI:1184407314
Name:VITAL, DOMANIQUE (LMSW)
Entity type:Individual
Prefix:
First Name:DOMANIQUE
Middle Name:
Last Name:VITAL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 WILLOW CHASE BLVD APT 821
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-6801
Mailing Address - Country:US
Mailing Address - Phone:713-398-9009
Mailing Address - Fax:
Practice Address - Street 1:12801 BRANT ROCK DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-5416
Practice Address - Country:US
Practice Address - Phone:832-288-2523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110667104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker