Healthcare Provider Details

I. General information

NPI: 1396698726
Provider Name (Legal Business Name): DOMINIQUE BULLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22790 SW 112TH AVE
MIAMI FL
33170-7602
US

IV. Provider business mailing address

23419 SW 127TH PL
HOMESTEAD FL
33032-9215
US

V. Phone/Fax

Practice location:
  • Phone: 305-609-1470
  • Fax:
Mailing address:
  • Phone: 305-609-1470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW25515
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: