Provider Demographics
NPI:1144855933
Name:DOMANSKI, SANDRA COLLINS (PT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:COLLINS
Last Name:DOMANSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:FL
Mailing Address - Zip Code:33877-0550
Mailing Address - Country:US
Mailing Address - Phone:863-521-0402
Mailing Address - Fax:
Practice Address - Street 1:1750 LONGLEAF BLVD # 5&6
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-2504
Practice Address - Country:US
Practice Address - Phone:863-678-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT4390225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty