Provider Demographics
NPI:1629426762
Name:DOMOTO, BETHANY (OTR/L)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:DOMOTO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 DEMPSEY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-3006
Mailing Address - Country:US
Mailing Address - Phone:815-355-9999
Mailing Address - Fax:
Practice Address - Street 1:210 DEMPSEY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714
Practice Address - Country:US
Practice Address - Phone:815-355-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5855-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist