Provider Demographics
NPI:1427726207
Name:TAGLIAFERRO, DOMINIQUE R
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:R
Last Name:TAGLIAFERRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 W MCNICHOLS RD STE 323-1120
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2357
Mailing Address - Country:US
Mailing Address - Phone:313-208-7692
Mailing Address - Fax:
Practice Address - Street 1:12822 TERRY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2575
Practice Address - Country:US
Practice Address - Phone:313-208-7692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-05
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374U00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician