Healthcare Provider Details

I. General information

NPI: 1104783869
Provider Name (Legal Business Name): DOMINIQUE FOSTER LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 STONEHILL LN
MATTHEWS NC
28104-6117
US

IV. Provider business mailing address

5060 STONEHILL LN
MATTHEWS NC
28104-6117
US

V. Phone/Fax

Practice location:
  • Phone: 954-240-0505
  • Fax:
Mailing address:
  • Phone: 954-240-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP023526
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-31150
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: