Provider Demographics
NPI:1932759677
Name:DESHIELDS, DOMONIQUE R (LPC, LPCMH, LMSW)
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:R
Last Name:DESHIELDS
Suffix:
Gender:F
Credentials:LPC, LPCMH, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 BRADBURN VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3868
Mailing Address - Country:US
Mailing Address - Phone:302-353-2604
Mailing Address - Fax:
Practice Address - Street 1:990 VILLA ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94041-1236
Practice Address - Country:US
Practice Address - Phone:888-688-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-15
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-0011050101YM0800X
LA9542101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional