Healthcare Provider Details

I. General information

NPI: 1649394099
Provider Name (Legal Business Name): ALEJANDRO DOMINGO SMALL OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 OREGON AVE NW
WASHINGTON DC
20015-1543
US

IV. Provider business mailing address

1743 HAMPTON CT
BONITA CA
91902-4011
US

V. Phone/Fax

Practice location:
  • Phone: 202-541-0403
  • Fax:
Mailing address:
  • Phone: 909-374-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number05746
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT010000400
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT4122
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119004495
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: