Provider Demographics
NPI:1679067771
Name:GARCIA O'DELL, DOMINIQUE IRENE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:IRENE
Last Name:GARCIA O'DELL
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 1:1240 CEDAR AVE APT 25
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3144
Mailing Address - Country:US
Mailing Address - Phone:857-225-0503
Mailing Address - Fax:
Practice Address - Street 1:11698 HURON ST UNIT 106
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-2950
Practice Address - Country:US
Practice Address - Phone:720-381-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician