Individual
DOMINQUE LATREACE WATHAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CMII, BHWC
Contact information
Practice address
111 W. 1ST ST, SHAWNEE, OK 74804-2202
(405) 273-1170
(405) 241-6447
Mailing address
111 W 1ST ST, CHANDLER, OK 74834-2004
(405) 273-1170
(405) 241-6447
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
175T00000X
Peer Specialist
—
—
Other
Enumeration date
10/28/2019
Last updated
03/04/2025
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