Provider Demographics
NPI:1609672781
Name:PICKETT, DOMINIQUE NIASIA (MA, ATR-P, LAAT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NIASIA
Last Name:PICKETT
Suffix:
Gender:
Credentials:MA, ATR-P, LAAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07063-1424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1114 W 5TH ST
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07063-1424
Practice Address - Country:US
Practice Address - Phone:908-391-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ6LA00002100221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist