Provider Demographics
NPI:1780340802
Name:SMITH, DOMONIQUE
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3253 CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3106
Mailing Address - Country:US
Mailing Address - Phone:989-475-4171
Mailing Address - Fax:
Practice Address - Street 1:3253 CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3106
Practice Address - Country:US
Practice Address - Phone:989-475-4171
Practice Address - Fax:989-393-6021
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MI6401225006101YM0800X, 101YP2500X, 101YM0800X
MI6451022099101YM0800X
6451022099101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional