Provider Demographics
NPI:1750930053
Name:SAINT AMAND, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:SAINT AMAND
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 1:180 BROADWAY UNIT 2
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4230
Mailing Address - Country:US
Mailing Address - Phone:516-935-6858
Mailing Address - Fax:
Practice Address - Street 1:180 BROADWAY UNIT 2
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4230
Practice Address - Country:US
Practice Address - Phone:516-935-6858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113422018Medicaid