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General NPI Number Information
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NPI Number | 1649637604
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Entity Type | Individual
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Provider Name | DOMINIQUE DAVID
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Gender | Female
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Dates
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Enumeration Date | 01/21/2016
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Last Update Date | 02/14/2023
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Provider Practice Location Address
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Address Line | 3000 LEE ROAD 279
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City | SALEM
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State | AL
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Zip | 36874-4776
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Country | US
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Telephone | 706-617-4315
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Fax |
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Provider Business Mailing Address
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Address Line | 3000 LEE ROAD 279
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City | SALEM
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State | AL
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Zip | 36874-4776
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Country | US
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Telephone | 706-617-4315
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Fax |
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC012370
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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