=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942546585
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIQUE BRIANNA DI CARMINE LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2013
-----------------------------------------------------
Last Update Date | 03/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 CENTER ST
-----------------------------------------------------
City | NEW PALTZ
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12561-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-750-6913
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 243 BAILEYS GAP RD
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12528-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-656-4534
-----------------------------------------------------
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 | 022579
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------