Provider Demographics
NPI:1811763717
Name:DICKINSON, DOMINIQUE KATHERINE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:KATHERINE
Last Name:DICKINSON
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 1:214 RICHMOND PARK PL
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3052
Mailing Address - Country:US
Mailing Address - Phone:619-701-8028
Mailing Address - Fax:
Practice Address - Street 1:214 RICHMOND PARK PL
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3052
Practice Address - Country:US
Practice Address - Phone:619-701-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1167281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical