Provider Demographics
NPI:1427938521
Name:PARKER, DOMINIQUE KRYSTAL
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:KRYSTAL
Last Name:PARKER
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 1:928 BROADWAY STE 403
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-8151
Mailing Address - Country:US
Mailing Address - Phone:212-481-1055
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY STE 403
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8151
Practice Address - Country:US
Practice Address - Phone:212-481-1055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty