Healthcare Provider Details

I. General information

NPI: 1053784413
Provider Name (Legal Business Name): DOMINIQUE PHUA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2015
Last Update Date: 11/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

3249 HUNTINGTON WOODS DR SE APT F
KENTWOOD MI
49512-8128
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7215
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3743369
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: