MEDICARE: DR. ALAN CHARLES DOMIAN PH.D.

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	103T00000X	Psychologist	752	KS

General Provider Information

NPI Number	:	1093864936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALAN CHARLES DOMIAN PH.D.

Provider Business Mailing Address
First Line	:	4200 SOMERSET DR
Second Line	:	SUITE 254
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208-5217
Country	:	US
Telephone Number	:	913-381-1810
Fax Number	:	913-381-1836

Provider Business Practice Location Address
First Line	:	4200 SOMERSET DR
Second Line	:	SUITE 254
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208-5217
Country	:	US
Telephone Number	:	913-381-1810
Fax Number	:	913-381-1836

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

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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