Provider Demographics
NPI:1720048044
Name:DOMENCH, MARSHA LESLIE (PT)
Entity Type:Individual
Prefix:MS
First Name:MARSHA
Middle Name:LESLIE
Last Name:DOMENCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04843
Mailing Address - Country:US
Mailing Address - Phone:207-236-9084
Mailing Address - Fax:207-236-6407
Practice Address - Street 1:22 PARK STREET
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:ME
Practice Address - Zip Code:04843
Practice Address - Country:US
Practice Address - Phone:207-236-9084
Practice Address - Fax:207-236-6407
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT711225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDOMM6486Medicare ID - Type Unspecified