Provider Demographics
NPI:1609535608
Name:NESBIT, DOMINIQUE L
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:L
Last Name:NESBIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 EAST BLVD STE E1471
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5870
Mailing Address - Country:US
Mailing Address - Phone:980-300-0971
Mailing Address - Fax:
Practice Address - Street 1:1235 EAST BLVD STE E1471
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5870
Practice Address - Country:US
Practice Address - Phone:980-300-0971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-17
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program