Individual
MS. MARY DOMHAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
6800 LUCY CORR BLVD, CHESTERFIELD, VA 23832
(804) 706-5648
Mailing address
2819 JEFFERS DR, NORTH CHESTERFIELD, VA 23235-2439
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
0131001557
VA
Other
Enumeration date
03/22/2011
Last updated
03/20/2017
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