Healthcare Provider Details

I. General information

NPI: 1992446264
Provider Name (Legal Business Name): DOMINIQUE MARIE BERTOLINI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2022
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N 2ND ST FL 3
RICHMOND VA
23219-1359
US

IV. Provider business mailing address

501 N 2ND ST FL 3
RICHMOND VA
23219-1359
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9452
  • Fax:
Mailing address:
  • Phone: 804-828-9452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101289312
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA205370
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number99320
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: