Mary Domhan, COTA
Individual provider Active NPI Contractor · Chesterfield, VA
NPI 1033418645 · NPPES record last updated Mar 20, 2017
Key facts
- NPI
- 1033418645
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Contractor 171W00000X
- License
- 0131001557 (VA)
- Practice address
- 6800 Lucy Corr Blvd
Chesterfield, VA 23832 - Phone
- (804) 706-5648
- NPI assigned
- Mar 22, 2011
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0131001557 | VA | MD | Contractor |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Contractor | 171W00000X | 0131001557 | VA | Yes |
Addresses
Primary practice location
6800 Lucy Corr Blvd
Chesterfield, VA 23832
Mailing address
2819 Jeffers Dr
North Chesterfield, VA 23235-2439
Other providers in Chesterfield, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 20, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.