Provider Demographics
NPI:1780152272
Name:BECKHAM, DOMONIQUE SHANTAE (PT, DPT)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:SHANTAE
Last Name:BECKHAM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:138 OLD SAN ANTONIO RD STE 304
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-3491
Practice Address - Country:US
Practice Address - Phone:210-419-3144
Practice Address - Fax:210-764-5098
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-07109225100000X
GAPT013764225100000X
TX1359208225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist