Provider Demographics
NPI:1346430006
Name:MARTIN-MITCHELL, DOMINIQUE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:MARTIN-MITCHELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17415 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-5522
Mailing Address - Country:US
Mailing Address - Phone:253-536-3274
Mailing Address - Fax:
Practice Address - Street 1:17415 17TH AVE E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-5522
Practice Address - Country:US
Practice Address - Phone:253-536-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00003270261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00003270OtherINDUSTRIAL REHAB