Provider Demographics
NPI:1881109114
Name:MAYFIELD, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:MAYFIELD
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 1:500 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6532
Mailing Address - Country:US
Mailing Address - Phone:318-450-4911
Mailing Address - Fax:318-855-4396
Practice Address - Street 1:500 N 21ST ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6532
Practice Address - Country:US
Practice Address - Phone:318-450-4911
Practice Address - Fax:318-855-4396
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst