Provider Demographics
NPI:1770238586
Name:BEAVER, DOMINAE (COTA/L)
Entity Type:Individual
Prefix:
First Name:DOMINAE
Middle Name:
Last Name:BEAVER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 COUNTY RD 2455
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 STILLHOUSE RD
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75462-2029
Practice Address - Country:US
Practice Address - Phone:903-785-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217012224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant