Provider Demographics
NPI:1689860934
Name:DOMYAN, KRISTIN MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:DOMYAN
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 1:1750 W 4TH ST
Mailing Address - Street 2:OUTPATIENT THERAPY
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-1770
Mailing Address - Country:US
Mailing Address - Phone:419-520-2839
Mailing Address - Fax:
Practice Address - Street 1:1750 W 4TH ST
Practice Address - Street 2:OUTPATIENT THERAPY
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-1770
Practice Address - Country:US
Practice Address - Phone:419-520-2839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6252225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist