Provider Demographics
NPI:1184422156
Name:ROCKETT, DYNASTY DONMINIK
Entity type:Individual
Prefix:
First Name:DYNASTY
Middle Name:DONMINIK
Last Name:ROCKETT
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 1:117 GLEN CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1405
Mailing Address - Country:US
Mailing Address - Phone:618-857-0106
Mailing Address - Fax:
Practice Address - Street 1:117 GLEN CROSSING RD
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1405
Practice Address - Country:US
Practice Address - Phone:618-857-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-394965106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician