Healthcare Provider Details

I. General information

NPI: 1083545792
Provider Name (Legal Business Name): DOMINIQUE PHILLIPS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 MARKET ST
PHILADELPHIA PA
19139-4636
US

IV. Provider business mailing address

2023 WALNUT ST APT 1F
PHILADELPHIA PA
19103-4465
US

V. Phone/Fax

Practice location:
  • Phone: 856-209-5398
  • Fax:
Mailing address:
  • Phone: 856-209-5398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: