Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003354127 |
---|---|
Provider Name | Kendric Dominick |
First Address | Baton Rouge, LA 70805 |
Second Address | Baton Rouge, LA 70805-3215 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2017 |
Last Update Date | 09/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0000000 | (05) | LA |