Provider Demographics
NPI:1790292415
Name:DEDOMINIC, TESSA CAROLEEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:CAROLEEN
Last Name:DEDOMINIC
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 1:3031 S RUSSELL ST STE B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8523
Mailing Address - Country:US
Mailing Address - Phone:406-396-4130
Mailing Address - Fax:
Practice Address - Street 1:3031 S RUSSELL ST STE B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8523
Practice Address - Country:US
Practice Address - Phone:406-396-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08064225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist