Provider Demographics
NPI:1982807665
Name:CRAWFORD, DOMINIQUE SUZANNE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:SUZANNE
Last Name:CRAWFORD
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 1109
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-0110
Mailing Address - Country:US
Mailing Address - Phone:925-646-9270
Mailing Address - Fax:925-646-9276
Practice Address - Street 1:4645 PACHECO BLVD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-3625
Practice Address - Country:US
Practice Address - Phone:925-646-9270
Practice Address - Fax:925-646-9276
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070012BN3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children