Provider Demographics
NPI:1942301064
Name:DOMINO, ANDREA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:DOMINO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:FARMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4510 MEDICAL CENTER DR STE 109
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-1624
Mailing Address - Country:US
Mailing Address - Phone:972-547-8081
Mailing Address - Fax:
Practice Address - Street 1:4510 MEDICAL CENTER DR STE 109
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-1624
Practice Address - Country:US
Practice Address - Phone:972-547-8081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1108264225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T4506OtherBCBS
TX8G0023Medicare ID - Type Unspecified