MEDICARE: DOMINIQUE STONE MSW, LCSWA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	P0014834	NC

General Provider Information

NPI Number	:	1942812813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE STONE MSW, LCSWA

Provider Business Mailing Address
First Line	:	5230 ROCKY BRANCH DR APT 306
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-5276
Country	:	US
Telephone Number	:	540-598-6267
Fax Number	:

Provider Business Practice Location Address
First Line	:	2128 MCCLINTOCK RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-5114
Country	:	US
Telephone Number	:	980-939-0991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2020
Last Update Date	:	08/20/2020

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