Provider Demographics
NPI:1003354143
Name:DOMINGUEZ, KRISTEN (L/COTA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:L/COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 32ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-1404
Mailing Address - Country:US
Mailing Address - Phone:504-723-6687
Mailing Address - Fax:
Practice Address - Street 1:719 SEVERN AVE
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-5150
Practice Address - Country:US
Practice Address - Phone:504-430-9218
Practice Address - Fax:504-835-2821
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTA.200502224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant