Provider Demographics
NPI:1043665102
Name:DOMITROVICH, MINDI (LMT)
Entity Type:Individual
Prefix:
First Name:MINDI
Middle Name:
Last Name:DOMITROVICH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3831 PIPER ST STE S220
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4680
Mailing Address - Country:US
Mailing Address - Phone:907-563-3145
Mailing Address - Fax:
Practice Address - Street 1:3831 PIPER ST STE S220
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4680
Practice Address - Country:US
Practice Address - Phone:907-563-3145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK967742225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist