Provider Demographics
NPI:1104979012
Name:VEDRINE, DOMINIQUE (MA)
Entity type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:
Last Name:VEDRINE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:V
Other - Last Name:CHUKU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:213 E BUTLER RD STE D1
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2172
Mailing Address - Country:US
Mailing Address - Phone:864-735-7416
Mailing Address - Fax:
Practice Address - Street 1:213 E BUTLER RD # 310
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2171
Practice Address - Country:US
Practice Address - Phone:864-735-7416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC4583106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health