Provider Demographics
NPI:1265980304
Name:LIGHT, DOMINIQUE NICOLE (MOTR/L)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NICOLE
Last Name:LIGHT
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:NICOLE
Other - Last Name:HARDAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:7001A LOISDALE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-1904
Mailing Address - Country:US
Mailing Address - Phone:703-971-0602
Mailing Address - Fax:703-971-0606
Practice Address - Street 1:176 W UNIVERSITY PKWY STE E
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1618
Practice Address - Country:US
Practice Address - Phone:313-004-9507
Practice Address - Fax:731-300-4951
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MD0119007097225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist