=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699072785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOMINIQUE MARGUERITE PHD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2011
-----------------------------------------------------
Last Update Date | 02/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 BOTTICELLI STREET
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-1306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-699-1664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1155
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-0506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-699-1664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DOMINIQUE MARGUERITE
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 503-699-1664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1241
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------