Provider Demographics
NPI:1558056010
Name:DOMAILLE, EMILY J (PTA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:J
Last Name:DOMAILLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3281
Mailing Address - Country:US
Mailing Address - Phone:920-803-1617
Mailing Address - Fax:920-803-1622
Practice Address - Street 1:1125 N 13TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3281
Practice Address - Country:US
Practice Address - Phone:920-803-1617
Practice Address - Fax:920-803-1622
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3070-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant