Provider Demographics
NPI:1124787411
Name:DOMINIQUE, MACIE
Entity type:Individual
Prefix:
First Name:MACIE
Middle Name:
Last Name:DOMINIQUE
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 1:12712 E CASPIAN PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1975
Mailing Address - Country:US
Mailing Address - Phone:720-263-6244
Mailing Address - Fax:
Practice Address - Street 1:2323 S TROY ST STE 6-200
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1984
Practice Address - Country:US
Practice Address - Phone:720-263-6244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional