Provider Demographics
NPI:1922327709
Name:DOMENICO, KATHIE
Entity Type:Individual
Prefix:
First Name:KATHIE
Middle Name:
Last Name:DOMENICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 E CARDINAL ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-1734
Mailing Address - Country:US
Mailing Address - Phone:417-234-7235
Mailing Address - Fax:417-823-9937
Practice Address - Street 1:314 E CARDINAL ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-1734
Practice Address - Country:US
Practice Address - Phone:417-234-7235
Practice Address - Fax:417-823-9937
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005018686224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant