Provider Demographics
NPI:1780217943
Name:MARSTON, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:MARSTON
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 1:2983 NC HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-9216
Mailing Address - Country:US
Mailing Address - Phone:910-315-2226
Mailing Address - Fax:
Practice Address - Street 1:925 CONFERENCE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5971
Practice Address - Country:US
Practice Address - Phone:252-686-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst