Provider Demographics
NPI:1689175796
Name:SOURIAL, DOMINICA (DPT)
Entity Type:Individual
Prefix:DR
First Name:DOMINICA
Middle Name:
Last Name:SOURIAL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:DOMINICA
Other - Middle Name:
Other - Last Name:HANNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:125 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:NJ
Mailing Address - Zip Code:07933-1608
Mailing Address - Country:US
Mailing Address - Phone:908-938-7898
Mailing Address - Fax:
Practice Address - Street 1:100 US-206
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:NJ
Practice Address - Zip Code:07934
Practice Address - Country:US
Practice Address - Phone:212-733-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01776900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist