Provider Demographics
NPI:1770819195
Name:WORRELL, DOMINIC MICHAEL (ATC)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:MICHAEL
Last Name:WORRELL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48915-1841
Mailing Address - Country:US
Mailing Address - Phone:517-505-8033
Mailing Address - Fax:
Practice Address - Street 1:802 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-1841
Practice Address - Country:US
Practice Address - Phone:517-505-8033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer