Provider Demographics
NPI:1477046811
Name:SHORT, DOMINIKA ROSE
Entity Type:Individual
Prefix:
First Name:DOMINIKA
Middle Name:ROSE
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 NE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4132
Mailing Address - Country:US
Mailing Address - Phone:541-517-3183
Mailing Address - Fax:
Practice Address - Street 1:1851 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4132
Practice Address - Country:US
Practice Address - Phone:541-517-3183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24424225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist