Provider Demographics
NPI:1790259463
Name:ROUGEAU, DOMINIQUE MICHELLEE (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MICHELLEE
Last Name:ROUGEAU
Suffix:
Gender:
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18840 NW ROCK CREEK CIR APT 285
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-7204
Mailing Address - Country:US
Mailing Address - Phone:337-292-5906
Mailing Address - Fax:618-418-4422
Practice Address - Street 1:1905 TYBEE LN
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4172
Practice Address - Country:US
Practice Address - Phone:337-240-8162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LAL-344103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3647681Medicaid