Provider Demographics
NPI:1023029568
Name:ANTEDOMENICO, NORMA R (PT)
Entity Type:Individual
Prefix:MS
First Name:NORMA
Middle Name:R
Last Name:ANTEDOMENICO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 APPLECROSS LN
Mailing Address - Street 2:
Mailing Address - City:POTTSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75076-3809
Mailing Address - Country:US
Mailing Address - Phone:940-300-5953
Mailing Address - Fax:
Practice Address - Street 1:275 APPLECROSS LN
Practice Address - Street 2:
Practice Address - City:POTTSBORO
Practice Address - State:TX
Practice Address - Zip Code:75076-3809
Practice Address - Country:US
Practice Address - Phone:940-300-5953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11222652251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T4408OtherBLUE CROSS PROVIDER NUMBE
TX456619OtherMEDICARE PTAN