Provider Demographics
NPI:1366177602
Name:BELLEGARDE, DOMINIQUE (CLC,CLE,CCHW)
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:
Last Name:BELLEGARDE
Suffix:
Gender:F
Credentials:CLC,CLE,CCHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 WASHINGTON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-3971
Mailing Address - Country:US
Mailing Address - Phone:617-892-3634
Mailing Address - Fax:
Practice Address - Street 1:306 WASHINGTON ST APT 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02121-3971
Practice Address - Country:US
Practice Address - Phone:617-329-1277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X, 176B00000X
MA374J00000X
MACHW00280172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No176B00000XOther Service ProvidersMidwife
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA33659OtherLACTATION