Provider Demographics
NPI:1447372784
Name:VAN DOMELEN, CASSANDRA LOUISE (OTRL)
Entity type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:LOUISE
Last Name:VAN DOMELEN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:CASSANDRA
Other - Middle Name:LOUISE
Other - Last Name:CONOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:627 NE EVANS ST
Mailing Address - Street 2:ABACUS PROGRAM
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-3923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:627 NE EVANS ST
Practice Address - Street 2:ABACUS PROGRAM
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-3923
Practice Address - Country:US
Practice Address - Phone:503-434-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR01028937225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist