Provider Demographics
NPI:1427451921
Name:PANCOTTO, DOMINIQUE CONSTINTINA
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:CONSTINTINA
Last Name:PANCOTTO
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 1:36599 LODGE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-3319
Mailing Address - Country:US
Mailing Address - Phone:586-747-2159
Mailing Address - Fax:
Practice Address - Street 1:36599 LODGE DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-3319
Practice Address - Country:US
Practice Address - Phone:586-747-2159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIP 523 149 122 197247200000X
MI7401001258103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other