Provider Demographics
NPI:1871186304
Name:DOMITRZ, BRYAN JOSEPH (ATC, LAT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JOSEPH
Last Name:DOMITRZ
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W792 POTTERS CIR
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-2317
Mailing Address - Country:US
Mailing Address - Phone:414-828-4911
Mailing Address - Fax:
Practice Address - Street 1:501 N PARKSIDE RD
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2780
Practice Address - Country:US
Practice Address - Phone:309-557-4402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0049692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty