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General NPI Number Information
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NPI Number | 1477702850
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Entity Type | Individual
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Provider Name | JEAN C DOMINIQUE LMSW
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Gender | Male
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Dates
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Enumeration Date | 09/10/2008
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Last Update Date | 10/22/2008
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Provider Practice Location Address
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Address Line | 160 LENOX RD
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City | NORTH BALDWIN
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State | NY
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Zip | 11510-1016
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Country | US
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Telephone | 516-377-6249
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Fax | 718-221-7240
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Provider Business Mailing Address
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Address Line | 160 LENOX RD
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City | NORTH BALDWIN
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State | NY
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Zip | 11510-1016
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Country | US
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Telephone | 516-377-6249
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Fax | 718-221-7240
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 071318-1
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License Number State | NY
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