Basic Information
Provider Information | |||||||||
NPI: | 1376051326 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUSTER | ||||||||
FirstName: | DOMINIQUE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 107 S DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992021510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098384651 | ||||||||
FaxNumber: | 5093632762 | ||||||||
Practice Location | |||||||||
Address1: | 131 S DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992021510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098384651 | ||||||||
FaxNumber: | 5093632762 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2018 | ||||||||
LastUpdateDate: | 09/04/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CG60757127 | WA | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 390200000X |   |   | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
ID Information
ID | Type | State | Issuer | Description | CG60757127 | 01 | WA | CARE COORDINATION | OTHER |