Provider Demographics
NPI:1356798128
Name:DOMINGOS, ANDRE DIVINE
Entity type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:DIVINE
Last Name:DOMINGOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17420 GALLAGHER WAY
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-2059
Mailing Address - Country:US
Mailing Address - Phone:240-377-1700
Mailing Address - Fax:
Practice Address - Street 1:17420 GALLAGHER WAY
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-2059
Practice Address - Country:US
Practice Address - Phone:240-377-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02204224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant