Provider Demographics
NPI:1730749755
Name:VEGT, DOMONIQUE RAE
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:RAE
Last Name:VEGT
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 1:2922 FULLER AVE NE UNIT 105
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3459
Mailing Address - Country:US
Mailing Address - Phone:616-327-6191
Mailing Address - Fax:
Practice Address - Street 1:2922 FULLER AVE NE UNIT 105
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3459
Practice Address - Country:US
Practice Address - Phone:616-570-0925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013552APP23225X00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician