MEDICARE: MS. DOMINIQUE JENELLE CLOTHIAUX CPM, LM, LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA00020937	WA
2	176B00000X	Midwife	0129000142	VA

General Provider Information

NPI Number	:	1770635203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DOMINIQUE JENELLE CLOTHIAUX CPM, LM, LMP

Provider Business Mailing Address
First Line	:	1142 SAINT CLAIR AVE
Second Line	:
City	:	CHARLOTTESVILLE
State	:	VA
Zip	:	22901-4144
Country	:	US
Telephone Number	:	434-996-5095
Fax Number	:	866-522-3846

Provider Business Practice Location Address
First Line	:	1142 SAINT CLAIR AVE
Second Line	:
City	:	CHARLOTTESVILLE
State	:	VA
Zip	:	22901-4144
Country	:	US
Telephone Number	:	434-996-5095
Fax Number	:	866-522-3846

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	04/22/2019

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