Provider Demographics
NPI:1548450372
Name:DOMINICZAK, LORI (PT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:DOMINICZAK
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 1:4002 W CHERRYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4002 W CHERRYWOOD LN
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1002
Practice Address - Country:US
Practice Address - Phone:414-378-3375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2714-0242251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40440700Medicaid