Provider Demographics
NPI:1912754235
Name:FERGUSON, DOMINIQUE NICOLLE (ITDS)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NICOLLE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1347 IVYHEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5020
Mailing Address - Country:US
Mailing Address - Phone:904-217-9732
Mailing Address - Fax:
Practice Address - Street 1:13014 N DALE MABRY HWY # 659
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2808
Practice Address - Country:US
Practice Address - Phone:813-215-6275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist