Provider Demographics
NPI:1699327957
Name:WATSON, DOMINIQUE NICOLE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NICOLE
Last Name:WATSON
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 1:3055 WILSHIRE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1147
Mailing Address - Country:US
Mailing Address - Phone:213-375-3830
Mailing Address - Fax:
Practice Address - Street 1:3055 WILSHIRE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1147
Practice Address - Country:US
Practice Address - Phone:213-375-3830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner