Healthcare Provider Details

I. General information

NPI: 1861075319
Provider Name (Legal Business Name): DOMINIQUE DIAMOND-RAE WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 TUPELO DR
CITRUS HEIGHTS CA
95621-1741
US

IV. Provider business mailing address

7512 WACHTEL WAY
ORANGEVALE CA
95662-2169
US

V. Phone/Fax

Practice location:
  • Phone: 916-729-3098
  • Fax:
Mailing address:
  • Phone: 916-751-9670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number24395467
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: