Provider Demographics
NPI:1972753549
Name:POTTER, DOMENICA DISALVO (OT)
Entity type:Individual
Prefix:MRS
First Name:DOMENICA
Middle Name:DISALVO
Last Name:POTTER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LONG ACRE CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2127
Mailing Address - Country:US
Mailing Address - Phone:632-675-4511
Mailing Address - Fax:631-675-4503
Practice Address - Street 1:6 LONG ACRE CT
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2127
Practice Address - Country:US
Practice Address - Phone:632-675-4511
Practice Address - Fax:631-675-4503
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003779-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist