MEDICARE: DOMINIQUE DAVID

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	101YP2500X	Professional Counselor	LPC012370	GA
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1649637604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE DAVID

Provider Business Mailing Address
First Line	:	3000 LEE ROAD 279
Second Line	:
City	:	SALEM
State	:	AL
Zip	:	36874-4776
Country	:	US
Telephone Number	:	706-617-4315
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 LEE ROAD 279
Second Line	:
City	:	SALEM
State	:	AL
Zip	:	36874-4776
Country	:	US
Telephone Number	:	706-617-4315
Fax Number	:

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

Provider Enumeration Date	:	01/21/2016
Last Update Date	:	02/14/2023

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