Healthcare Provider Details

I. General information

NPI: 1205293768
Provider Name (Legal Business Name): KAYCE DOMINGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 04/16/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N VAUGHAN DR
BRUSLY LA
70719-2217
US

IV. Provider business mailing address

6450 LA HIGHWAY 1
BATCHELOR LA
70715-3212
US

V. Phone/Fax

Practice location:
  • Phone: 225-385-2668
  • Fax: 225-343-0626
Mailing address:
  • Phone: 225-492-3775
  • Fax: 225-492-3782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number7371
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7371
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: