Provider Demographics
NPI:1437281714
Name:DOMENECH, SUSAN ESTHER (MPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ESTHER
Last Name:DOMENECH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 AUBURN CT
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4277
Mailing Address - Country:US
Mailing Address - Phone:909-794-9570
Mailing Address - Fax:
Practice Address - Street 1:27620 LANDAU BLVD
Practice Address - Street 2:STE 3
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-5540
Practice Address - Country:US
Practice Address - Phone:760-322-5090
Practice Address - Fax:760-322-9175
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ59189Medicare UPIN
CA0PT261800Medicare PIN