Individual
DOMINIQUE L GIST
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
8674 S 165TH AVE, GOODYEAR, AZ 85338-1447
(313) 434-6821
Mailing address
11213 W IVORY LN, AVONDALE, AZ 85392-3916
(313) 434-6821
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
—
—
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
323P00000X
Psychiatric Residential Treatment Facility
Primary
—
—
324500000X
Substance Abuse Rehabilitation Facility
—
—
332800000X
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
—
—
Other
Enumeration date
12/05/2020
Last updated
12/05/2020
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