Individual
DOMINIQUE MARIE SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
BS
Contact information
Practice address
631 S 1ST ST, DEKALB, IL 60115-4117
(815) 756-8501
Mailing address
PO BOX 1109, DEKALB, IL 60115-7109
(815) 756-8501
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
474579189001
—
IL
Enumeration date
08/09/2019
Last updated
08/09/2019
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