=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215654025
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIQUE MYESHA CARSON LMT, MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2022
-----------------------------------------------------
Last Update Date | 10/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 529 N GREAT NECK RD
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-4035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-463-0091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1008 RIVER BIRCH CT APT 202
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-309-8034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 0019017766
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------