Provider Demographics
NPI:1407381973
Name:STEVENSON, DOMINIQUE
Entity type:Individual
Prefix:MISS
First Name:DOMINIQUE
Middle Name:
Last Name:STEVENSON
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 1:6800 RASBERRY LN APT 1901
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-2525
Mailing Address - Country:US
Mailing Address - Phone:318-834-5287
Mailing Address - Fax:
Practice Address - Street 1:6800 RASBERRY LANE APT.1901
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129
Practice Address - Country:US
Practice Address - Phone:318-834-5287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist