Provider Demographics
NPI:1215654025
Name:CARSON, DOMINIQUE MYESHA (LMT, MS)
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:MYESHA
Last Name:CARSON
Suffix:
Gender:F
Credentials:LMT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 RIVER BIRCH CT APT 202
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-5138
Mailing Address - Country:US
Mailing Address - Phone:347-309-8034
Mailing Address - Fax:
Practice Address - Street 1:529 N GREAT NECK RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4035
Practice Address - Country:US
Practice Address - Phone:757-463-0091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019017766225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist