Provider Demographics
NPI:1730843269
Name:DAVIS, DOMINIQUE (PTA)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S KENMORE AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-2419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3392 MOTOR AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3712
Practice Address - Country:US
Practice Address - Phone:310-742-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty