Provider Demographics
NPI:1477617520
Name:HENDERSHOT EMBREY, DOMENIQUE CAROL (OTD MSOTR L)
Entity Type:Individual
Prefix:
First Name:DOMENIQUE
Middle Name:CAROL
Last Name:HENDERSHOT EMBREY
Suffix:
Gender:F
Credentials:OTD MSOTR L
Other - Prefix:
Other - First Name:DOMENIQUE
Other - Middle Name:H
Other - Last Name:EMBREY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:484 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-2821
Mailing Address - Country:US
Mailing Address - Phone:510-794-5990
Mailing Address - Fax:
Practice Address - Street 1:2021 FILLMORE ST # 1367
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2708
Practice Address - Country:US
Practice Address - Phone:415-236-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT3300225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist