Provider Demographics
NPI:1770982423
Name:LEARY, DOMINIQUE (DPT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:LEARY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13690 HIGHWAY 51 S STE 104
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004-7645
Mailing Address - Country:US
Mailing Address - Phone:901-259-4254
Mailing Address - Fax:901-725-8353
Practice Address - Street 1:13690 HIGHWAY 51 S STE 104
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004-7645
Practice Address - Country:US
Practice Address - Phone:901-259-4254
Practice Address - Fax:901-725-8353
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25119225100000X, 2251X0800X
TN15045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic