Provider Demographics
NPI:1407223704
Name:NELSON, DOMINIQUE S (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:S
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8520 WHITE POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-8636
Mailing Address - Country:US
Mailing Address - Phone:813-658-8106
Mailing Address - Fax:
Practice Address - Street 1:3117 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5632
Practice Address - Country:US
Practice Address - Phone:813-662-1106
Practice Address - Fax:813-661-7661
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12741235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist