Provider Demographics
NPI:1356605323
Name:PRITCHETT, DOMINIQUE SHANTELLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:SHANTELLE
Last Name:PRITCHETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 15TH ST
Mailing Address - Street 2:APT. 2C
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4717
Mailing Address - Country:US
Mailing Address - Phone:262-496-8897
Mailing Address - Fax:
Practice Address - Street 1:4536 22ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5917
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:262-653-2218
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI128010-1211041C0700X
WI7981-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical