Healthcare Provider Details

I. General information

NPI: 1265310817
Provider Name (Legal Business Name): MR. NATHANIEL JAMES DOMINY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 BREMO RD STE 101
RICHMOND VA
23226-2438
US

IV. Provider business mailing address

1317 N 34TH ST
RICHMOND VA
23223-6836
US

V. Phone/Fax

Practice location:
  • Phone: 804-918-1115
  • Fax:
Mailing address:
  • Phone: 703-507-2262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0734013814
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: