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General NPI Number Information
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NPI Number | 1104412261
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Entity Type | Individual
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Provider Name | DUSTIN J DONAHUE LMBT #4824
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Gender | Male
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Dates
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Enumeration Date | 12/14/2020
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Last Update Date | 12/14/2020
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Provider Practice Location Address
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Address Line | 630 S BENNETT ST STE 2
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City | SOUTHERN PINES
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State | NC
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Zip | 28387-5920
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Country | US
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Telephone | 910-973-1049
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Fax |
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Provider Business Mailing Address
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Address Line | 125 WOODED ACRE WAY
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City | CAMERON
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State | NC
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Zip | 28326-0108
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Country | US
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Telephone | 910-973-1049
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 4824
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License Number State | NC
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