Healthcare Provider Details

I. General information

NPI: 1164163655
Provider Name (Legal Business Name): DOMINIQUE ANTAWN MILLS LPC-R
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 MCLAWS CIR
WILLIAMSBURG VA
23185-5660
US

IV. Provider business mailing address

247 MCLAWS CIR
WILLIAMSBURG VA
23185-5660
US

V. Phone/Fax

Practice location:
  • Phone: 757-253-0111
  • Fax:
Mailing address:
  • Phone: 757-253-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0709024174
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0704014275
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: