Provider Demographics
NPI:1487460465
Name:RICHARDSON, DOMINIQUE (LMT)
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5608
Mailing Address - Country:US
Mailing Address - Phone:318-323-7246
Mailing Address - Fax:
Practice Address - Street 1:1400 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5608
Practice Address - Country:US
Practice Address - Phone:318-323-7246
Practice Address - Fax:318-323-7265
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA9190225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist