Provider Demographics
NPI:1740815489
Name:DOMINIQUE, EDNA
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4931 NW 85TH TER
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33351-5454
Mailing Address - Country:US
Mailing Address - Phone:561-843-9709
Mailing Address - Fax:
Practice Address - Street 1:4931 NW 85TH TER
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33351-5454
Practice Address - Country:US
Practice Address - Phone:561-843-9709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17-43975106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician