Healthcare Provider Details

I. General information

NPI: 1780831065
Provider Name (Legal Business Name): DOMINIQUE JODIE DOSEDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 UNIVERSITY AVE
LAS VEGAS NM
87701-4250
US

IV. Provider business mailing address

720 UNIVERSITY AVE
LAS VEGAS NM
87701-4250
US

V. Phone/Fax

Practice location:
  • Phone: 575-454-8265
  • Fax:
Mailing address:
  • Phone: 575-454-8265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT - 0113251
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: