Provider Demographics
NPI:1164038881
Name:DOMIANO, ANNA ELIZABETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:ELIZABETH
Last Name:DOMIANO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-2527
Mailing Address - Country:US
Mailing Address - Phone:585-200-2247
Mailing Address - Fax:
Practice Address - Street 1:750 MAIDEN LN
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14615-1230
Practice Address - Country:US
Practice Address - Phone:585-966-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY031138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program