Provider Demographics
NPI:1609992593
Name:DOMEN, HENRY JR
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:DOMEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S WILTSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-3515
Mailing Address - Country:US
Mailing Address - Phone:301-932-1840
Mailing Address - Fax:
Practice Address - Street 1:107 S WILTSHIRE CT
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-3515
Practice Address - Country:US
Practice Address - Phone:301-932-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1279225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant