Provider Demographics
NPI:1639809601
Name:DOMENICK, MARIA ASTRID (OT)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:ASTRID
Last Name:DOMENICK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13248 MISTY SAGE DR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77302-3147
Mailing Address - Country:US
Mailing Address - Phone:936-648-2939
Mailing Address - Fax:
Practice Address - Street 1:6203 ALDEN BRIDGE DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77382-5121
Practice Address - Country:US
Practice Address - Phone:936-648-2939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102658225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist