Provider Demographics
NPI:1720255201
Name:DOMINA, JEREMY C (OTR)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:C
Last Name:DOMINA
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 OLD ROUTE 15
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:VT
Mailing Address - Zip Code:05444-9772
Mailing Address - Country:US
Mailing Address - Phone:802-310-1511
Mailing Address - Fax:
Practice Address - Street 1:49 LYME RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-1205
Practice Address - Country:US
Practice Address - Phone:603-643-2854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1702225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist