=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073368460
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIQUE MCIVERY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2024
-----------------------------------------------------
Last Update Date | 04/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 DORWIL DR APT A
-----------------------------------------------------
City | COVENTRY TOWNSHIP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44319-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-785-8526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 DORWIL DR APT A
-----------------------------------------------------
City | COVENTRY TOWNSHIP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44319-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------