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General NPI Number Information
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NPI Number | 1265561005
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Entity Type | Individual
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Provider Name | LISETTE C DOMITEAUX PH. D.
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Gender | Female
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 01/09/2024
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Provider Practice Location Address
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Address Line | 5925 FOREST LANE SUITE 202
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City | DALLAS
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State | TX
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Zip | 75230-8805
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Country | US
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Telephone | 214-363-0277
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Fax | 214-352-5388
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Provider Business Mailing Address
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Address Line | 5925 FOREST LANE SUITE 202
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City | DALLAS
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State | TX
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Zip | 75230-8805
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Country | US
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Telephone | 214-363-0277
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Fax | 214-352-5388
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 8717
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License Number State | TX
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