Provider Demographics
NPI:1992349427
Name:WATHAN, DOMINQUE LATREACE (CMII, BHWC)
Entity type:Individual
Prefix:
First Name:DOMINQUE
Middle Name:LATREACE
Last Name:WATHAN
Suffix:
Gender:
Credentials:CMII, BHWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-2004
Mailing Address - Country:US
Mailing Address - Phone:405-273-1170
Mailing Address - Fax:405-241-6447
Practice Address - Street 1:111 W. 1ST ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2202
Practice Address - Country:US
Practice Address - Phone:405-273-1170
Practice Address - Fax:405-241-6447
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist