Provider Demographics
NPI:1407097363
Name:DOMS, CYNTHIA LOU
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LOU
Last Name:DOMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:BARTHOLOMAUS
Other - Last Name:DOMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7525 MITCHELL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-1959
Mailing Address - Country:US
Mailing Address - Phone:952-224-2282
Mailing Address - Fax:952-224-2284
Practice Address - Street 1:7525 MITCHELL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-1959
Practice Address - Country:US
Practice Address - Phone:952-224-2282
Practice Address - Fax:952-224-2284
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health