Healthcare Provider Details

I. General information

NPI: 1992450019
Provider Name (Legal Business Name): DOMINIQUE MANNERINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 W BELTLINE HWY
MADISON WI
53713-2848
US

IV. Provider business mailing address

6225 SMITH AVE STE 1001A
BALTIMORE MD
21209-3626
US

V. Phone/Fax

Practice location:
  • Phone: 608-819-6810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-203703
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: