Healthcare Provider Details

I. General information

NPI: 1689148397
Provider Name (Legal Business Name): DOMINIQUE DIJKHUIZEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LANARK TRL
SOUTHERN PINES NC
28387-7513
US

IV. Provider business mailing address

216 COMMERCE AVE # 189
SOUTHERN PINES NC
28387-7059
US

V. Phone/Fax

Practice location:
  • Phone: 719-270-1722
  • Fax:
Mailing address:
  • Phone: 719-270-1722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1689148397
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: