Provider Demographics
NPI:1437158102
Name:DOMINGUEZ, MARYANN THERESA (PT)
Entity Type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:THERESA
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 LADY MARIAN LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-1178
Mailing Address - Country:US
Mailing Address - Phone:804-677-6786
Mailing Address - Fax:
Practice Address - Street 1:2820 WATERFORD LAKE DR STE 103
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3994
Practice Address - Country:US
Practice Address - Phone:804-249-8277
Practice Address - Fax:804-249-9690
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004526225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
007390T41Medicare PIN
VA007390T41Medicare ID - Type UnspecifiedPHYSICAL THERAPIST