Individual
DOMONIQUE DICKERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1340 W TUNNEL BLVD STE 230, HOUMA, LA 70360-2811
(985) 293-7322
(985) 231-1377
Mailing address
1418 TIGER DR, THIBODAUX, LA 70301-4337
(985) 449-4055
(985) 449-4178
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
LA
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2203783561
—
LA
Enumeration date
12/28/2018
Last updated
04/03/2020
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