=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275865149
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG DOMANSKI M.A., BCBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2010
-----------------------------------------------------
Last Update Date | 02/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 CENTRAL AVE
-----------------------------------------------------
City | PORT MONMOUTH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07758-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-812-0766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 CENTRAL AVE
-----------------------------------------------------
City | PORT MONMOUTH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07758-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------