=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184407314
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMANIQUE VITAL LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2023
-----------------------------------------------------
Last Update Date | 08/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12801 BRANT ROCK DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77082-5416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-288-2523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7700 WILLOW CHASE BLVD APT 821
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-6801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-398-9009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 110667
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------