Individual
DOMINIQUE WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
214 WESTSIDE BLVD, APT. 6, ROANOKE, VA 24017
(540) 278-9002
Mailing address
214 WESTSIDE BLVD, APT. 6, ROANOKE, VA 24017
(540) 278-9002
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
RBT-23-281401
VA
Other
Enumeration date
06/25/2024
Last updated
06/25/2024
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