Healthcare Provider Details

I. General information

NPI: 1316868342
Provider Name (Legal Business Name): DOMINIQUE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1172 KENSINGTON
BUFFALO NY
14215
US

IV. Provider business mailing address

1172 KENSINGTON
BUFFALO NY
14215
US

V. Phone/Fax

Practice location:
  • Phone: 716-812-1321
  • Fax:
Mailing address:
  • Phone: 716-812-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number018205
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: