Healthcare Provider Details

I. General information

NPI: 1316408941
Provider Name (Legal Business Name): DOMINIQUE DANIELLE CRAFT PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 37TH ST
PARKERSBURG WV
26101-1009
US

IV. Provider business mailing address

415 36TH ST STE 100
PARKERSBURG WV
26101-1005
US

V. Phone/Fax

Practice location:
  • Phone: 304-428-1703
  • Fax: 304-422-1176
Mailing address:
  • Phone: 304-917-3660
  • Fax: 304-917-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017915
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT004092
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: