Provider Demographics
NPI:1245984996
Name:BALDERAS, DOMINIQUE (LPC)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:BALDERAS
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W317S3439 STATE ROAD 83 APT B
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9428
Mailing Address - Country:US
Mailing Address - Phone:414-759-5247
Mailing Address - Fax:
Practice Address - Street 1:W317S3439 STATE ROAD 83 APT B
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-9428
Practice Address - Country:US
Practice Address - Phone:414-759-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19426101YA0400X
WI11434125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)