Provider Demographics
NPI:1326073685
Name:STO DOMINGO, JUDIE M
Entity Type:Individual
Prefix:
First Name:JUDIE
Middle Name:M
Last Name:STO DOMINGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDIE
Other - Middle Name:MAE AMOUR
Other - Last Name:TAMPUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1021 CHERAW STREET
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512
Mailing Address - Country:US
Mailing Address - Phone:843-454-9000
Mailing Address - Fax:843-454-9001
Practice Address - Street 1:1021 CHERAW STREET
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512
Practice Address - Country:US
Practice Address - Phone:843-454-9000
Practice Address - Fax:843-454-9001
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1257Medicaid
SCTH1257Medicaid