Provider Demographics
NPI:1811497910
Name:HALE, DOMINIQUE NICHOLE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NICHOLE
Last Name:HALE
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:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-1015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8115 COLUMBIA 100 PARKWAY
Practice Address - Street 2:SUITE 4
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045
Practice Address - Country:US
Practice Address - Phone:877-776-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-17-41405.106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician