MEDICARE: DR. DOMINIQUE BLANCHETTE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY11190	FL

General Provider Information

NPI Number	:	1154086890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOMINIQUE BLANCHETTE PHD

Provider Business Mailing Address
First Line	:	10590 CITY CENTER BLVD APT 204
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33025-4656
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10590 CITY CENTER BLVD APT 204
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33025-4656
Country	:	US
Telephone Number	:	916-730-1538
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2021
Last Update Date	:	11/08/2021

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