Provider Demographics
NPI:1629866587
Name:KINNEY, DOMINIQUE (COTA/L)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:KINNEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6R FERNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2947
Mailing Address - Country:US
Mailing Address - Phone:630-873-9210
Mailing Address - Fax:
Practice Address - Street 1:753 DALHART AVE
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-1156
Practice Address - Country:US
Practice Address - Phone:815-866-7827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.006226224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant