Provider Demographics
NPI:1700686730
Name:BUFFA, DOMINIQUE MARIE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MARIE
Last Name:BUFFA
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 1:4407 CLAYBORNE DR APT 302
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2751
Mailing Address - Country:US
Mailing Address - Phone:845-245-8522
Mailing Address - Fax:
Practice Address - Street 1:801 HAZEN ST STE C
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-2008
Practice Address - Country:US
Practice Address - Phone:845-245-8522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851118637104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker