Provider Demographics
NPI:1871965533
Name:JUAREZ, DOMINIQUE DAVI (LCSW-39611)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:DAVI
Last Name:JUAREZ
Suffix:
Gender:M
Credentials:LCSW-39611
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E HERITAGE PARK ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6293
Mailing Address - Country:US
Mailing Address - Phone:208-371-8420
Mailing Address - Fax:
Practice Address - Street 1:314 BADIOLA ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4389
Practice Address - Country:US
Practice Address - Phone:208-454-8389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-396111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCSW39611Other.