Provider Demographics
NPI:1063197077
Name:BROWN, DOMINIQUE ELITA
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:ELITA
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 S CLAIBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-7810
Mailing Address - Country:US
Mailing Address - Phone:310-993-4374
Mailing Address - Fax:
Practice Address - Street 1:2200 E WILLIAMS FIELD RD STE 200
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-0764
Practice Address - Country:US
Practice Address - Phone:855-730-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)