Provider Demographics
NPI:1487172482
Name:WILLIAMS, DOMINIQUE ANN (MA, MA, PD)
Entity type:Individual
Prefix:MISS
First Name:DOMINIQUE
Middle Name:ANN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MA, MA, PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 PARK AVE SOUTH
Mailing Address - Street 2:APT# 17PHO
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010
Mailing Address - Country:US
Mailing Address - Phone:917-279-1273
Mailing Address - Fax:
Practice Address - Street 1:295 PARK AVE SOUTH
Practice Address - Street 2:APT# 17PHO
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010
Practice Address - Country:US
Practice Address - Phone:917-279-1273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2790832103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty