Provider Demographics
NPI:1861708273
Name:DOMRZALSKI, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:DOMRZALSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1179 E GOLDCREST ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-3128
Mailing Address - Country:US
Mailing Address - Phone:480-522-0388
Mailing Address - Fax:
Practice Address - Street 1:1910 S STAPLEY DR STE 221
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6680
Practice Address - Country:US
Practice Address - Phone:480-573-2662
Practice Address - Fax:480-573-2169
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL23899235Z00000X
AZTSLP6794235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1265153761OtherGROUP NPI