Provider Demographics
NPI:1497577811
Name:ROBERTS, DOMINIQUE J
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:J
Last Name:ROBERTS
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 1:996 ROYAL MARCO WAY
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36-35 BELL BLVD FL 3
Practice Address - Street 2:SUITE 304
Practice Address - City:QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11361
Practice Address - Country:US
Practice Address - Phone:347-321-4094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY789651990106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician