Provider Demographics
NPI:1245051564
Name:MARSEILLE, DOMONIQUE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:MARSEILLE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3694 MERIDIAN LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7729
Mailing Address - Country:US
Mailing Address - Phone:404-919-5341
Mailing Address - Fax:
Practice Address - Street 1:3694 MERIDIAN LN
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7729
Practice Address - Country:US
Practice Address - Phone:404-904-2591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-19
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP013094235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist