Provider Demographics
NPI:1003149709
Name:DOMFORT, SUSAN MARIE (LMT,HMLDT,COTA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:DOMFORT
Suffix:
Gender:F
Credentials:LMT,HMLDT,COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 SE 19TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-5324
Mailing Address - Country:US
Mailing Address - Phone:352-804-7617
Mailing Address - Fax:352-622-6100
Practice Address - Street 1:1328 SE 25TH LOOP
Practice Address - Street 2:SUITE 101
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-1026
Practice Address - Country:US
Practice Address - Phone:352-804-7617
Practice Address - Fax:352-622-6100
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-12
Last Update Date:2009-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA53889225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist