Provider Demographics
NPI:1336854983
Name:FRYER, DOMYNYQUE (LPC)
Entity type:Individual
Prefix:
First Name:DOMYNYQUE
Middle Name:
Last Name:FRYER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 ABERDEEN RD UNIT 9626
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23670-1224
Mailing Address - Country:US
Mailing Address - Phone:757-660-3157
Mailing Address - Fax:
Practice Address - Street 1:600 MEDICAL DR STE A&B
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1769
Practice Address - Country:US
Practice Address - Phone:757-788-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011954101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659424448Medicaid