Provider Demographics
NPI:1295135424
Name:DOMOGALIK, AMY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:DOMOGALIK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:WYMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2705 N LEBANON ST STE 305
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8622
Mailing Address - Country:US
Mailing Address - Phone:765-485-8852
Mailing Address - Fax:
Practice Address - Street 1:2485 E WABASH ST STE 100
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-9400
Practice Address - Country:US
Practice Address - Phone:765-485-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06000978A225100000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist