Provider Demographics
NPI:1558067389
Name:DOMINY, MICHAEL (MT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DOMINY
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6062 CIDER MILL PL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80925-1419
Mailing Address - Country:US
Mailing Address - Phone:518-593-4119
Mailing Address - Fax:
Practice Address - Street 1:76 S SIERRA MADRE ST STE B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3399
Practice Address - Country:US
Practice Address - Phone:719-413-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0024506225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist