Healthcare Provider Details

I. General information

NPI: 1831661842
Provider Name (Legal Business Name): DEBORAH A DOMINO APTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 S COLORADO ST STE A
GREENVILLE MS
38703-7275
US

IV. Provider business mailing address

1707 S COLORADO ST STE A
GREENVILLE MS
38703-7275
US

V. Phone/Fax

Practice location:
  • Phone: 662-335-8332
  • Fax: 662-335-8852
Mailing address:
  • Phone: 662-335-8332
  • Fax: 662-335-8852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA6145
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: