Basic Information
| Provider Information | |||||||||
| NPI: | 1780831065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOSEDO | ||||||||
| FirstName: | DOMINIQUE | ||||||||
| MiddleName: | JODIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877014250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754548265 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 720 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877014250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754548265 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2008 | ||||||||
| LastUpdateDate: | 08/19/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | T - 0113251 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.