MEDICARE: DOMINIQUE CONSTINTINA PANCOTTO

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	247200000X	Other Technician	P 523 149 122 197	MI
2	103K00000X	Behavior Analyst	7401001258	MI

General Provider Information

NPI Number	:	1427451921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE CONSTINTINA PANCOTTO

Provider Business Mailing Address
First Line	:	36599 LODGE DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48312-3319
Country	:	US
Telephone Number	:	586-747-2159
Fax Number	:

Provider Business Practice Location Address
First Line	:	36599 LODGE DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48312-3319
Country	:	US
Telephone Number	:	586-747-2159
Fax Number	:

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

Provider Enumeration Date	:	09/29/2014
Last Update Date	:	02/07/2024

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Directions to “ DOMINIQUE CONSTINTINA PANCOTTO ” Practice Location

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