Provider Demographics
NPI:1740990878
Name:DOMINIQUE, ANGELICA
Entity type:Individual
Prefix:
First Name:ANGELICA
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 1:15722 POWELLS COVE BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:712 EGAN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11239-2819
Practice Address - Country:US
Practice Address - Phone:347-765-8934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst