=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740435189
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA DOMINIANNI MSPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2008
-----------------------------------------------------
Last Update Date | 11/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 292 MADISON AVE 2ND FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10017-6307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-888-3507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 HUDSON ST APT 12G
-----------------------------------------------------
City | HOBOKEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07030-5590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-888-3507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | 023394-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------