Provider Demographics
NPI:1588541775
Name:MEDINA, DOMINIQUE AILEEN
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:AILEEN
Last Name:MEDINA
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 1:215 W FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77520-2772
Mailing Address - Country:US
Mailing Address - Phone:346-710-3510
Mailing Address - Fax:
Practice Address - Street 1:19701 KINGWOOD DR STE 8
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3775
Practice Address - Country:US
Practice Address - Phone:281-973-0757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician