Basic Information
| Provider Information | |||||||||
| NPI: | 1891143996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | DOMINIQUE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 79 W ALEXANDRINE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138315535 | ||||||||
| FaxNumber: | 3138312608 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 W ALEXANDRINE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138315535 | ||||||||
| FaxNumber: | 3138312608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2016 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 6401017213 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 101Y00000X | 6401017213 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1891143996 | 05 | MI | MEDICAID |