MEDICARE: DOMINIQUE CORREA LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	18326	NC

General Provider Information

NPI Number	:	1417663659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE CORREA LCMHC

Provider Business Mailing Address
First Line	:	5306 FOX COVE LN APT D
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-5973
Country	:	US
Telephone Number	:	984-244-1695
Fax Number	:

Provider Business Practice Location Address
First Line	:	19901 W CATAWBA AVE STE 102
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-4040
Country	:	US
Telephone Number	:	804-613-4812
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2023
Last Update Date	:	02/20/2026

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