Provider Demographics
NPI:1689198822
Name:DOMIN, BRITTANY (OTR/L)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:DOMIN
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 1:2504 N WILLETTS CT UNIT 3S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-7704
Mailing Address - Country:US
Mailing Address - Phone:586-883-4691
Mailing Address - Fax:
Practice Address - Street 1:3200 GRANT ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1903
Practice Address - Country:US
Practice Address - Phone:734-216-4680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012023225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist