Provider Demographics
NPI:1265561005
Name:DOMITEAUX, LISETTE C (PH D)
Entity type:Individual
Prefix:
First Name:LISETTE
Middle Name:C
Last Name:DOMITEAUX
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 FOREST LANE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-8805
Mailing Address - Country:US
Mailing Address - Phone:214-363-0277
Mailing Address - Fax:214-352-5388
Practice Address - Street 1:5925 FOREST LANE
Practice Address - Street 2:SUITE 202
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-8805
Practice Address - Country:US
Practice Address - Phone:214-363-0277
Practice Address - Fax:214-352-5388
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8717101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752231883OtherFEDERAL TAX ID