Provider Demographics
NPI:1053038257
Name:WAITERS, DOMINIQUE LASHA
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LASHA
Last Name:WAITERS
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 1:225 CLARENDON AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4624
Mailing Address - Country:US
Mailing Address - Phone:234-207-6121
Mailing Address - Fax:
Practice Address - Street 1:225 CLARENDON AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4624
Practice Address - Country:US
Practice Address - Phone:234-207-6121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health