Provider Demographics
NPI:1063982890
Name:BROWN, DOMONIQUE NICOLE
Entity type:Individual
Prefix:MISS
First Name:DOMONIQUE
Middle Name:NICOLE
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:DOMONIQUE
Other - Middle Name:NICOLE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6685 SULLIVAN RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENWELL SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70739-3112
Mailing Address - Country:US
Mailing Address - Phone:225-261-7143
Mailing Address - Fax:225-250-1026
Practice Address - Street 1:6685 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:GREENWELL SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70739-3112
Practice Address - Country:US
Practice Address - Phone:225-261-7143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health