1447899703 NPI number — MRS. DOMINIQUE SIMONE REYES LCSW

Table of content: MRS. DOMINIQUE SIMONE REYES LCSW (NPI 1447899703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447899703 NPI number — MRS. DOMINIQUE SIMONE REYES LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYES
Provider First Name:
DOMINIQUE
Provider Middle Name:
SIMONE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447899703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 W 40TH ST UNIT 2225
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37409-1379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-358-2998
Provider Business Mailing Address Fax Number:
423-405-6346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5721 LOOP RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33811-2321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-427-9804
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW20741 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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